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CA OMFS - Reimbursements Reduced for Physician Services

CA OMFS - Reimbursements Reduced for Physician Services

Yesterday, the California Division of Workers’ Compensation (DWC) announced the 2021 reimbursement changes to the Physician Services section of the Official Medical Fee Schedule (OMFS), to conform to relevant 2021 changes in the Medicare payment system as required by Labor Code section 5307.1.

The Order, effective for services rendered on or after March 1, 2021, as well as related documents, can be found at the DWC OMFS physician fee schedule webpage.

We’ll summarize the changes, analyze the reduced reimbursements for physician services, and share a handy chart of the new, higher rates for California-specific codes.

The changes include the customary adoption of updated Medicare RVU files and GPCIs, Current Procedural Terminology (CPT), etc. In addition, of particular note this year are the following changes which we explore in more depth below:

  1. Reimbursement reduction for Physician Services
  2. Revisions relating to Evaluation and Management (E&M) services for office visits for new and established patients
  3. California-specific codes increased reimbursement

Physician Services Reduced Reimbursements - 1.97%

For all dates of services on or after March 1, 2021, Physician Services reimbursements, other than anesthesia, will be calculated using a reduced conversion factor of $45.87. The current conversion factor for dates of services January 1, 2020 through February 28, 2021 is $46.79.

The reduced conversation factor represents a 1.97% reduction in reimbursements paid for Physician Services.

Remember, the reimbursement calculation for Physician Services also requires updated Medicare RVU values and updated GPCI values.

Evaluation and Management (E&M) Revisions

The DWC revised § 9789.12.11. Evaluation and Management: Coding – New Patient; Documentation to adopt the most recent American Medical Association’s Current Procedural Terminology (CPT) E&M office visit code descriptors and guidelines as follows:

  • 1995 and 1997 Evaluation and Management Documentation Guidelines are no longer used
  • Starting for dates of service on or after March 1, 2021, level of E&M office visit service is reported using either level of medical decision making or total time
  • First level new patient office visit code CPT 99201 has been eliminated
  • Medicare Prolonged Service Code HCPCS G2212 is adopted for use in place of CPT code 99417 for prolonged E&M service provided on the date of service where the level of service is selected based upon time

California-Specific Codes Reimbursements Increase

In the Physician Fee Schedule, these state-specific codes cover services for which there are no appropriate CPT Codes, such as the Primary Treating Physician’s Progress Report (DWC Form PR-2). Annually, California’s Division of Workers’ Compensation (DWC) establishes a single new statewide reimbursement for each of the services covered by these ‘WC’ codes. For reference, these codes are authorized by California Code of Regulations §9789.12.14.

Below, we’ve put together a helpful table summarizing the increased reimbursements effective for all dates of service on or after March 1, 2021.

California-Specific Code

Description

Reimbursement Amount

Additional Page Reimbursement

WC001

Doctor’s First Report of Occupational Illness or Injury (Form 5021)

Not reimbursable

WC002

Primary Treating Physician’s Progress Report (Form PR-2)

$13.70

WC003

Primary Treating Physician’s Permanent & Stationary Report (Form PR-3)

$42.43 for first page

$26.09 each additional page. Maximum of six pages absent mutual agreement ($172.88)

WC004

Primary Treating Physician’s Permanent & Stationary Report (Form PR-4)

$42.43 for first page

$26.09 each additional page. Maximum of seven pages absent mutual agreement ($198.97)

WC005

Psychiatric Report requested by the WCAB or the Administrative Director, other than medical-legal report

$42.43 for first page

$26.09 each additional page. Maximum of six pages absent mutual agreement ($172.88)

WC007

Consultation Reports requested by the WCAB or the Administrative Director

$42.43 for first page

$26.09 each additional page. Maximum of six pages absent mutual agreement ($172.88)

WC008

Chart Notes

$12.25 for up to the first 15 pages

$0.25 for each additional page after the first 15 pages

WC009

Duplicate Reports

$12.25 for up to the first 15 pages

$0.25 for each additional page after the first 15 pages

WC010

Duplication of X-Ray

$5.62 per x-ray

WC011

Duplication of Scan

$12.25 per scan

WC012

Missed Appointments. This code is designated for communication only. It does not imply that compensation is owed. Non-reimbursable absent agreement.

No Fee Prescribed/Non Reimbursable absent agreement


Our annual webinar on OMFS changes is coming up on March 9! This year, our free webinar will cover topics including increased reimbursements for both E/M and CA-specific codes, a new extended time code, and telehealth billing updates.

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