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CA OMFS Update: Outpatient/ASC Changes Effective October 1

October 4, 2018 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 raises 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:

  1.  The CMS Medicare Hospital Outpatient Prospective Payment System (OPPS) October 2018 Addendum A quarterly update
  2. The CMS Medicare OPPS October 2018 Addendum B quarterly update
  3. 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”
  4. Certain sections of the CMS Medicare OPPS October 2018 Integrated Outpatient Code Editor (I/OCE), IntegOCEspecsV19.3 quarterly update
  5. 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 increases in reimbursement, with 95 of the 193 increasing by less than $1. 97 of the 193 increases range from $1.68 to $12.43.

The remaining code, CPT 0308T for inserting an ocular telescope prosthesis, increases 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.

TRY THE OMFS CALCULATOR

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