Yesterday, California’s Division of Workers’ Compensation (DWC) announced reimbursement updates to the Physician and Non-Physician Practitioner Services section of the Official Medical Fee Schedule (OMFS), effective for services rendered on or after February 15, 2023. 

Despite the Centers for Medicare and Medicaid Services (CMS) cutting the Conversion Factor by which Medicare reimbursements are calculated, California increased the Conversion Factor that applies to its physician fee schedule services. California also increased the flat-rate reimbursements for California-specific ‘WC’ billing codes.

(Unfortunately, this OMFS “raise” will not increase reimbursements for the many providers ensnared in Preferred Provider Organization (PPO) and other discount reimbursement contracts.)

Below are details regarding both the increased OMFS Conversion Factor and the increased California-specific billing code reimbursements.

Higher OMFS Conversion Factor

The OMFS update announcement is found in this recent DWC Newsline, with the update order and related documents available on the DWC’s OMFS web page.

The Conversion Factor used to calculate OMFS reimbursements for physician services is increasing from $46.45 to $47.21 (even as Medicare rates decrease); the OMFS will pay 139.32% of Medicare rates for the same services.

With this Conversion Factor increase, the DWC is acknowledging that treating injured workers requires about 40% more work than treating a Medicare patient — though California still allows PPOs to drastically reduce reimbursement rates to well below OMFS (and sometimes even below Medicare) rates.

The table below displays the historical Medicare Conversion Factors, as compared to historical OMFS Conversion Factors. The ‘OMFS % of Medicare’ column shows the precise difference between the two Conversion Factors — which reflects the substantial difference in administrative expenses required when treating an injured worker as opposed to a Medicare patient.

daisyWizard Fee Schedule Calculator

The daisyWizard Fee Schedule Calculator is already updated to reflect the fee schedule changes described above (feel free to try the OMFS Calculator free to instantly know the new reimbursements).

Below, daisyWizard shows the new reimbursement rate (effective February 15th) for Los Angeles for CPT code 99214, a common Evaluation and Management (E/M) code — increasing to $196.29 from the current rate of $191.01.

As a reminder, California also adopted the new Medicare RVU and GPCI values, both of which also impact the calculation of the reimbursement for each procedure code.

California-Specific ‘WC’ Codes: Reimbursement Increase

California Code of Regulations Section 9789.12.14 establishes “California Specific Codes,” which begin with the prefix “WC.” Physicians report these codes when submitting reports or furnishing copies of chart notes, x-rays, or scans.

For example, a Primary Treating Physician (PTP) reports code WC002 when submitting the required PR-2 progress report for an injured worker. As of February 15th, the reimbursement for WC002 will increase to $14.52, up from the previous rate of $13.99.

Annually, the DWC establishes new statewide reimbursement rates for these ‘WC’ codes. The table below outlines the reimbursement rates due for all dates of service on or after February 15, 2023.

OMFS vs PPOs

The increase in reimbursement rates as a result of this update should be good news for California physicians — but it will mean nothing for those physicians bullied into PPO discount contracts, usually under threat of exclusion from Medical Provider Networks (MPNs).

Sadly, California continues to allow providers who treat injured workers to be reimbursed at or below Medicare rates, through the machinations of PPOs and other discount contracting entities.

We will explore the issue of OMFS rates versus the actual reimbursement received under various kinds of discount contracts in future posts. Stay tuned to this space.

Know (and receive) exactly what you’re owed for treating injured workers. Get instant, accurate fee schedule calculations with daisyWizard’s OMFS Calculator.

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