CA OMFS Update: Outpatient/ASC Changes Effective October 1

October 4, 2018 9 min read

By: Catherine Montgomery

California’s Division of Workers’ Compensation (DWC) ordered updates to the Hospital Outpatient and Ambulatory Surgical Center (ASC) portion of the Official Medical Fee Schedule (OMFS), effective October 1, 2018. The updates bring the OMFS into line with changes to the Medicare payment system.

The update lowers reimbursements for 193 billing codes.

OPP To It

California Labor Code Section 5307.1 mandates updates to the OMFS that keep workers’ comp reimbursement rates in alignment with Medicare.

The OMFS pegs reimbursement rates for both hospital outpatient and ASC services to Medicare’s Hospital Outpatient Fee Schedule. Workers’ comp hospital outpatient rates may not exceed 120% of Medicare hospital outpatient rates, while workers’ comp ASC services rates may not exceed 80% of Medicare hospital outpatient rates.

The update order, announced in a recent DWC Newsline, adopts five Medicare changes:

The CMS Medicare Hospital Outpatient Prospective Payment System (OPPS) October 2018 Addendum A quarterly update
The CMS Medicare OPPS October 2018 Addendum B quarterly update
The CMS Ambulatory Surgical Center Payment System, October 2018 ASC Approved HCPCS Code and Payment Rates – Updated 09/19/2018, Column A entitled “HCPCS Code” of “Oct 2018 ASC AA” and Column A entitled “HCPCS Code” of “Oct 2018 ASC EE”
Certain sections of the CMS Medicare OPPS October 2018 Integrated Outpatient Code Editor (I/OCE), IntegOCEspecsV19.3 quarterly update
CMS October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS), Change Request (CR) 10923 (released August 24, 2018), Transmittal R4123CP

Reimbursement Changes

The updates adjust reimbursement for 193 billing codes as indicated in the table below. All changes represent decreases in reimbursement, with 95 of the 193 decreasing by less than $1. 97 of the 193 decreases range from $1.68 to $12.43.

The remaining code, CPT 0308T for inserting an ocular telescope prosthesis, decreases by $168.94.

Billing Code	Status Indicator	Procedure	Reimbursement 9/30/18	Reimbursement 10/1/18	Reimbursement Difference
31720	Q1	Clearance of airways	215.93	215.92	-0.01
20500	T	Injection of sinus tract	1318.66	1318.54	-0.12
21073	T	Mnpj of tmj w/anesth	1318.66	1318.54	-0.12
21076	T	Prepare face/oral prosthesis	1318.66	1318.54	-0.12
21110	Q2	Interdental fixation	1318.66	1318.54	-0.12
21295	T	Revision of jaw muscle/bone	1318.66	1318.54	-0.12
21315	T	Closed tx nose fx w/o stablj	1318.66	1318.54	-0.12
21345	T	Closed tx nose/jaw fx	1318.66	1318.54	-0.12
21401	T	Closed tx orbit w/manipulj	1318.66	1318.54	-0.12
21451	T	Treat lower jaw fracture	1318.66	1318.54	-0.12
21485	T	Reset dislocated jaw	1318.66	1318.54	-0.12
21497	T	Interdental wiring	1318.66	1318.54	-0.12
30100	T	Intranasal biopsy	1318.66	1318.54	-0.12
30110	T	Removal of nose polyp(s)	1318.66	1318.54	-0.12
30124	T	Removal of nose lesion	1318.66	1318.54	-0.12
30210	T	Nasal sinus therapy	1318.66	1318.54	-0.12
30220	T	Insert nasal septal button	1318.66	1318.54	-0.12
30320	T	Remove nasal foreign body	1318.66	1318.54	-0.12
30801	T	Ablate inf turbinate superf	1318.66	1318.54	-0.12
30802	T	Ablate inf turbinate submuc	1318.66	1318.54	-0.12
31002	T	Irrigation sphenoid sinus	1318.66	1318.54	-0.12
31603	T	Incision of windpipe	1318.66	1318.54	-0.12
40654	T	Repair lip	1318.66	1318.54	-0.12
40819	T	Excise lip or cheek fold	1318.66	1318.54	-0.12
41006	T	Drainage of mouth lesion	1318.66	1318.54	-0.12
41007	T	Drainage of mouth lesion	1318.66	1318.54	-0.12
41010	T	Incision of tongue fold	1318.66	1318.54	-0.12
41018	T	Drainage of mouth lesion	1318.66	1318.54	-0.12
41115	T	Excision of tongue fold	1318.66	1318.54	-0.12
41805	T	Removal foreign body gum	1318.66	1318.54	-0.12
41806	T	Removal foreign body jawbone	1318.66	1318.54	-0.12
41821	T	Excision of gum flap	1318.66	1318.54	-0.12
41822	T	Excision of gum lesion	1318.66	1318.54	-0.12
41850	T	Treatment of gum lesion	1318.66	1318.54	-0.12
42100	T	Biopsy roof of mouth	1318.66	1318.54	-0.12
42300	T	Drainage of salivary gland	1318.66	1318.54	-0.12
42650	T	Dilation of salivary duct	1318.66	1318.54	-0.12
42900	T	Repair throat wound	1318.66	1318.54	-0.12
42955	T	Surgical opening of throat	1318.66	1318.54	-0.12
43020	T	Incision of esophagus	1318.66	1318.54	-0.12
60000	T	Drain thyroid/tongue cyst	1318.66	1318.54	-0.12
69105	T	Biopsy of external ear canal	1318.66	1318.54	-0.12
69436	T	Create eardrum opening	1318.66	1318.54	-0.12
69540	T	Remove ear lesion	1318.66	1318.54	-0.12
69700	T	Close mastoid fistula	1318.66	1318.54	-0.12
69801	T	Incise inner ear	1318.66	1318.54	-0.12
C9727	T	Insert palate implants	1318.66	1318.54	-0.12
65091	J1	Revise eye	3419.6	3419.43	-0.17
65093	J1	Revise eye with implant	3419.6	3419.43	-0.17
65101	J1	Removal of eye	3419.6	3419.43	-0.17
65103	J1	Remove eye/insert implant	3419.6	3419.43	-0.17
65105	J1	Remove eye/attach implant	3419.6	3419.43	-0.17
65110	J1	Removal of eye	3419.6	3419.43	-0.17
65112	J1	Remove eye/revise socket	3419.6	3419.43	-0.17
65114	J1	Remove eye/revise socket	3419.6	3419.43	-0.17
65130	J1	Insert ocular implant	3419.6	3419.43	-0.17
65135	J1	Insert ocular implant	3419.6	3419.43	-0.17
65140	J1	Attach ocular implant	3419.6	3419.43	-0.17
65150	J1	Revise ocular implant	3419.6	3419.43	-0.17
65155	J1	Reinsert ocular implant	3419.6	3419.43	-0.17
65175	J1	Removal of ocular implant	3419.6	3419.43	-0.17
65275	J1	Repair of eye wound	3419.6	3419.43	-0.17
65290	J1	Repair of eye socket wound	3419.6	3419.43	-0.17
65779	Q2	Cover eye w/membrane suture	3419.6	3419.43	-0.17
65780	J1	Ocular reconst transplant	3419.6	3419.43	-0.17
65782	J1	Ocular reconst transplant	3419.6	3419.43	-0.17
67218	J1	Treatment of retinal lesion	3419.6	3419.43	-0.17
67227	J1	Dstrj extensive retinopathy	3419.6	3419.43	-0.17
67312	J1	Revise two eye muscles	3419.6	3419.43	-0.17
67346	J1	Biopsy eye muscle	3419.6	3419.43	-0.17
67400	J1	Explore/biopsy eye socket	3419.6	3419.43	-0.17
67414	J1	Explr/decompress eye socket	3419.6	3419.43	-0.17
67420	J1	Explore/treat eye socket	3419.6	3419.43	-0.17
67430	J1	Explore/treat eye socket	3419.6	3419.43	-0.17
67440	J1	Explore/drain eye socket	3419.6	3419.43	-0.17
67445	J1	Explr/decompress eye socket	3419.6	3419.43	-0.17
67450	J1	Explore/biopsy eye socket	3419.6	3419.43	-0.17
67550	J1	Insert eye socket implant	3419.6	3419.43	-0.17
67560	J1	Revise eye socket implant	3419.6	3419.43	-0.17
67570	J1	Decompress optic nerve	3419.6	3419.43	-0.17
67902	J1	Repair eyelid defect	3419.6	3419.43	-0.17
67906	J1	Repair eyelid defect	3419.6	3419.43	-0.17
67974	J1	Reconstruction of eyelid	3419.6	3419.43	-0.17
68325	J1	Revise/graft eyelid lining	3419.6	3419.43	-0.17
68326	J1	Revise/graft eyelid lining	3419.6	3419.43	-0.17
68335	J1	Revise/graft eyelid lining	3419.6	3419.43	-0.17
68360	J1	Revise eyelid lining	3419.6	3419.43	-0.17
68500	J1	Removal of tear gland	3419.6	3419.43	-0.17
68505	J1	Partial removal tear gland	3419.6	3419.43	-0.17
68520	J1	Removal of tear sac	3419.6	3419.43	-0.17
68550	J1	Remove tear gland lesion	3419.6	3419.43	-0.17
68720	J1	Create tear sac drain	3419.6	3419.43	-0.17
68745	J1	Create tear duct drain	3419.6	3419.43	-0.17
68750	J1	Create tear duct drain	3419.6	3419.43	-0.17
62302	Q2	Myelography lumbar injection	790	788.32	-1.68
62303	Q2	Myelography lumbar injection	790	788.32	-1.68
62304	Q2	Myelography lumbar injection	790	788.32	-1.68
62305	Q2	Myelography lumbar injection	790	788.32	-1.68
65280	J1	Repair of eye wound	4183.31	4180.92	-2.39
65285	J1	Repair of eye wound	4183.31	4180.92	-2.39
65710	J1	Corneal transplant	4183.31	4180.92	-2.39
65730	J1	Corneal transplant	4183.31	4180.92	-2.39
65750	J1	Corneal transplant	4183.31	4180.92	-2.39
65755	J1	Corneal transplant	4183.31	4180.92	-2.39
65756	J1	Corneal trnspl endothelial	4183.31	4180.92	-2.39
65781	J1	Ocular reconst transplant	4183.31	4180.92	-2.39
65785	J1	Impltj ntrstrml crnl rng seg	4183.31	4180.92	-2.39
65820	J1	Relieve inner eye pressure	4183.31	4180.92	-2.39
65880	J1	Incise inner eye adhesions	4183.31	4180.92	-2.39
66150	J1	Glaucoma surgery	4183.31	4180.92	-2.39
66155	J1	Glaucoma surgery	4183.31	4180.92	-2.39
66174	J1	Translum dil eye canal	4183.31	4180.92	-2.39
66175	J1	Trnslum dil eye canal w/stnt	4183.31	4180.92	-2.39
66179	J1	Aqueous shunt eye w/o graft	4183.31	4180.92	-2.39
66180	J1	Aqueous shunt eye w/graft	4183.31	4180.92	-2.39
66183	J1	Insert ant drainage device	4183.31	4180.92	-2.39
66225	J1	Repair/graft eye lesion	4183.31	4180.92	-2.39
66600	J1	Remove iris and lesion	4183.31	4180.92	-2.39
66852	J1	Removal of lens material	4183.31	4180.92	-2.39
66930	J1	Extraction of lens	4183.31	4180.92	-2.39
67036	J1	Removal of inner eye fluid	4183.31	4180.92	-2.39
67039	J1	Laser treatment of retina	4183.31	4180.92	-2.39
67040	J1	Laser treatment of retina	4183.31	4180.92	-2.39
67041	J1	Vit for macular pucker	4183.31	4180.92	-2.39
67042	J1	Vit for macular hole	4183.31	4180.92	-2.39
67043	J1	Vit for membrane dissect	4183.31	4180.92	-2.39
67107	J1	Repair detached retina	4183.31	4180.92	-2.39
67108	J1	Repair detached retina	4183.31	4180.92	-2.39
67113	J1	Repair retinal detach cplx	4183.31	4180.92	-2.39
67115	J1	Release encircling material	4183.31	4180.92	-2.39
0191T	J1	Insert ant segment drain int	4183.31	4180.92	-2.39
0253T	J1	Insert aqueous drain device	4183.31	4180.92	-2.39
0449T	J1	Insj aqueous drain dev 1st	4183.31	4180.92	-2.39
0474T	J1	Insj aqueous drg dev io rsvr	4183.31	4180.92	-2.39
65770	J1	Revise cornea with implant	10643.86	10637.54	-6.32
65235	J1	Remove foreign body from eye	2225.71	2213.28	-12.43
65260	J1	Remove foreign body from eye	2225.71	2213.28	-12.43
65265	J1	Remove foreign body from eye	2225.71	2213.28	-12.43
65286	J1	Repair of eye wound	2225.71	2213.28	-12.43
65800	J1	Drainage of eye	2225.71	2213.28	-12.43
65810	J1	Drainage of eye	2225.71	2213.28	-12.43
65815	J1	Drainage of eye	2225.71	2213.28	-12.43
65850	J1	Incision of eye	2225.71	2213.28	-12.43
65865	J1	Incise inner eye adhesions	2225.71	2213.28	-12.43
65870	J1	Incise inner eye adhesions	2225.71	2213.28	-12.43
65875	J1	Incise inner eye adhesions	2225.71	2213.28	-12.43
65900	J1	Remove eye lesion	2225.71	2213.28	-12.43
65920	J1	Remove implant of eye	2225.71	2213.28	-12.43
65930	J1	Remove blood clot from eye	2225.71	2213.28	-12.43
66020	J1	Injection treatment of eye	2225.71	2213.28	-12.43
66030	J1	Injection treatment of eye	2225.71	2213.28	-12.43
66160	J1	Glaucoma surgery	2225.71	2213.28	-12.43
66170	J1	Glaucoma surgery	2225.71	2213.28	-12.43
66172	J1	Incision of eye	2225.71	2213.28	-12.43
66184	J1	Revision of aqueous shunt	2225.71	2213.28	-12.43
66185	J1	Revise aqueous shunt eye	2225.71	2213.28	-12.43
66220	J1	Repair eye lesion	2225.71	2213.28	-12.43
66500	J1	Incision of iris	2225.71	2213.28	-12.43
66505	J1	Incision of iris	2225.71	2213.28	-12.43
66605	J1	Removal of iris	2225.71	2213.28	-12.43
66625	J1	Removal of iris	2225.71	2213.28	-12.43
66630	J1	Removal of iris	2225.71	2213.28	-12.43
66635	J1	Removal of iris	2225.71	2213.28	-12.43
66680	J1	Repair iris & ciliary body	2225.71	2213.28	-12.43
66682	J1	Repair iris & ciliary body	2225.71	2213.28	-12.43
66700	J1	Destruction ciliary body	2225.71	2213.28	-12.43
66711	J1	Ciliary endoscopic ablation	2225.71	2213.28	-12.43
66820	J1	Incision secondary cataract	2225.71	2213.28	-12.43
66825	J1	Reposition intraocular lens	2225.71	2213.28	-12.43
66830	J1	Removal of lens lesion	2225.71	2213.28	-12.43
66840	J1	Removal of lens material	2225.71	2213.28	-12.43
66850	J1	Removal of lens material	2225.71	2213.28	-12.43
66920	J1	Extraction of lens	2225.71	2213.28	-12.43
66940	J1	Extraction of lens	2225.71	2213.28	-12.43
66982	J1	Cataract surgery complex	2225.71	2213.28	-12.43
66983	J1	Cataract surg w/iol 1 stage	2225.71	2213.28	-12.43
66984	J1	Cataract surg w/iol 1 stage	2225.71	2213.28	-12.43
66985	J1	Insert lens prosthesis	2225.71	2213.28	-12.43
66986	J1	Exchange lens prosthesis	2225.71	2213.28	-12.43
66999	J1	Eye surgery procedure	2225.71	2213.28	-12.43
67005	J1	Partial removal of eye fluid	2225.71	2213.28	-12.43
67010	J1	Partial removal of eye fluid	2225.71	2213.28	-12.43
67015	J1	Release of eye fluid	2225.71	2213.28	-12.43
67025	J1	Replace eye fluid	2225.71	2213.28	-12.43
67030	J1	Incise inner eye strands	2225.71	2213.28	-12.43
67101	J1	Repair detached retina crtx	2225.71	2213.28	-12.43
67110	J1	Repair detached retina	2225.71	2213.28	-12.43
67120	J1	Remove eye implant material	2225.71	2213.28	-12.43
67121	J1	Remove eye implant material	2225.71	2213.28	-12.43
67255	J1	Reinforce/graft eye wall	2225.71	2213.28	-12.43
67299	J1	Eye surgery procedure	2225.71	2213.28	-12.43
68330	J1	Revise eyelid lining	2225.71	2213.28	-12.43
0308T	J1	Insj ocular telescope prosth	20345.96	20177.02	-168.94

Our software is updated to reflect the latest changes, so DaisyBill clients will continue to obtain correct reimbursement. And as always, we’ll keep all our readers up to speed with any new OMFS developments.

Staying on top of ever-changing fee schedules is a full-time job. Fortunately, that’s what DaisyBill does. Our OMFS Calculator finds the right reimbursement according to the latest data. Try it free today.

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