Effective for dates of service on or after January 1st, 2016, California’s Division of Workers’ Compensation (DWC) changed reimbursements listed in the Official Medical Fee Schedules (OMFS).

Specifically, the reimbursement amounts changed for the following three fee schedules:

1. Physician and Non-Physician Services Fee Schedule
2. DMEPOS Fee Schedule
3. Pathology Fee Schedule

Below, find a brief summary of the reimbursement changes. To determine the new reimbursement amounts, daisyBill recommends subscribing to daisyBill’s OMFS Calculator. It’s free for the first three days.  

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1. Physician and Non-Physician Services Fee Schedule

Effective for dates of service on or after January 1st, 2016, California’s DWC adopted the following new values to calculate reimbursements for all procedure codes used for services provided by Physicians and Non-Physicians:

1. Four new Conversion Factors listed in CCR § 9789.19(c) and
2. Updated CMS Medicare National Physician Fee Schedule Relative Value File (File Name: RVU16A).

For procedure codes used by Physicians and Non-Physicians, these two new values change 100% of the reimbursement amounts and also add 632 new codes and delete 220 codes.

While the vastness of these reimbursement changes cannot be summarized in a single article, listed below is key information about the changes to the five procedure code categories.  

Other Services - Increased Reimbursements

The new Conversion Factor used for calculating reimbursements for procedure codes designated as ‘Other Services’ increased by 5.37% and CMS Medicare assigned new RVUs to many procedure codes.

Alert: Evaluation and Management (E/M) procedure codes are designated as ‘Other Services’; therefore, reimbursements increased for all of these frequently-used procedure code increased. DIR Newsline No.: 2015-124

Surgery - Decreased Reimbursements

The new Conversion Factor used for calculating reimbursements for procedure codes designated as ‘Surgical’ decreased by 6.69% and CMS Medicare assigned new RVUs to many procedure codes.

Alert: The Division of Workers’ Compensation (DWC)  also adopted the CMS’ Medicare revisions to the Place of Service (POS) Code for Outpatient Hospital Departments. CCR § 9789.12.2 reflects the adoption of the new POS Code 19 and the changed definition of POS Code 22.

Radiology - Decreased Reimbursements

The new Conversion Factor used for calculating reimbursements for procedure codes designated as ‘Radiology’ decreased by 5.44% and CMS Medicare assigned new RVUs to many procedure codes.

Alert: CMS Medicare deleted many frequently-used radiology procedure codes and replaced the deleted codes with new procedure codes. Avoid denials by using the correct new radiology codes and know the new reimbursement amounts.

Radiology procedure code examples:

Deleted codes: 73510, 73520, 73540, 73550

New codes: 73501, 73502, 73503, 73551

Anesthesia - Decreased Reimbursements

The new Conversion Factor used for calculating reimbursements for procedure codes designated as ‘Radiology’ decreased by 6.80% and CMS Medicare assigned new RVUs to many procedure codes.

California Specific Codes - Increased Reimbursements

All California specific codes increased as adjusted according to the Medicare Economic Index increase of +1.1%. DIR Newsline No.: 2015-109.

2. Pathology and Clinical Laboratory Fee Schedule

Effective for dates of service on or after January 1st, 2016, California’s DWC adopted CMS Medicare’s 2016 Clinical Laboratory Fee Schedule (electronic file 16CLAB). The OMFS reimbursements is calculated at 120% of the reimbursement listed in the CMS Medicare electronic file 16CLAB.

Alert: In addition to adopting Medicare’s Pathology Fee Schedule, the Division of Workers’ Compensation (DWC)  also adopted the CMS’ Medicare “Calendar Year (CY) 2016 Clinical Laboratory Fee Schedule (CLFS) Final Determinations”.  Effective for dates of service 1/1/2016, to determine correct reimbursements, it is important to read and understand the payment rules outlined in this document. DIR Newsline No.: 2015-127

3. DMEPOS Fee Schedule

Effective for dates of service on or after January 1st, 2016, the DWC adopted the California fees listed in CMS Medicare’s “Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule” revised for January 2016 (File name: DME16-A). The OMFS reimbursements are calculated at 120% of the reimbursement listed in the CMS Medicare DME16-A file.

Alert: The injured worker’s resident zip code determines whether the OMFS reimbursement is calculated using the CMS Medicare fee listed in the California Rural (R)  or Non-Rural (NR) columns.  DIR Newsline No.: 2015-122

Remember, California workers’ comp reimbursements change frequently. Accordingly, the links above will only work for the most recently announced changes and will not work for future updates.

For easy and up-to-date calculations, sign up for a free trial of daisyBill’s OMFS Calculator. daisyBill’s Calculator includes every update to seven workers’ comp fee schedules (including all the ones that just changed), simplifying calculations for both current and past dates of service.

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