Changes have been made to the California OMFS since the publication of this article. Be sure to see the latest analyses here and here.

2021 OMFS updates drastically changed how E/M codes are billed. The following information may not be applicable for DOS on and after March 1, 2021.

More good news! In 2020 California workers’ comp reimbursements increased for CPT Codes 99358 and 99359.

Below, we’ve compiled a handy reimbursement cheat sheet for these popular, but sometimes confusing, codes for non-face-to-face prolonged services (such as medical record review). The reimbursements are listed by locality of the place of service.

*Update: The 2021 OMFS updates drastically changed how E/M codes are billed. The following information may not be applicable for DOS on and after March 1, 2021.*

Time and Units: 99358 & 99359

The time requirements for CPT Codes 99358 and 99359 are strictly-defined as follows

• 99358 is for the first hour of non-face-to-face services and may be billed before or after direct patient care.
• 99359 is an add-on code, only billable in conjunction with 99358, for each additional half-hour spent. A provider must meet over half of the specified time before reporting these codes.

In other words, a provider must spend 30 minutes or more before billing code 99358, and 75 minutes or more before adding code 99359. A provider may report a maximum of two hours of non-face-to-face time using CPT Codes 99358 and 99359 per patient on any given day, which is equivalent to a maximum of one unit of 99358 and two units of 99359.

GPCI Reminder

Since 1/1/2019, California no longer reimburses providers using a single state-wide geographic adjustment factor (GAF). Instead, with the adoption of geographic practice cost indices (GPCIs) the reimbursement calculation now uses three location-based GPCIs (PW, PE, MP) assigned by Medicare.

Reimbursement for providers, with the adoption of Medicare GPCIs, varies depending on the location where services are provided to the injured worker.

2020 Reimbursements for 99358 & 99359

We organized this table from the lowest to highest reimbursement areas to give you an idea as to where you stand relative to the rest of the state.

These OMFS reimbursements are effective for dates of service on or after January 1, 2020.

For more in-depth information on CPT Codes 99358 and 99359, see some of our previous blogs posts:

• CPT 99358 - Maximus Correctly Rules in Favor of Provider (Hurray!) (11/2019)
• IBR Appeal Analysis for CPTs 99358 & 99359 (2/2019)
• The 5 Point Checklist for CPT Codes 99358 and 99359 (11/2018)
• Maximus Blunders AGAIN with 99358 Decision and a Math Error (9/2018)
• Time and Billable Units for CPT Codes 99358 and 99359 (9/2018)
• Maximus Gets It Wrong in 99358 IBR Decision (8/2017)
• Data! CPT 99358 Reimbursement (7/2017)
• Major NCCI Changes to CPT Code 99359 (4/2017)
• CPT Codes 99358 and 99359 Resource Notebook (3/2017)
• Non-Face-To-Face Service Reimbursable in 2017 (CPT Codes 99358, 99359) (2/2017)

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