§ 9789.19. Update Table.
8 CA ADC § 9789.19Barclays Official California Code of Regulations
8 CCR § 9789.19
§ 9789.19. Update Table.
Document | Services Rendered On or After 1/1/2014 |
---|---|
Adjustment Factors | For all services other than anesthesia: |
(These factors have been | 2014 Total RVS adjustment factor: 1.0477 |
incorporated into the | 2014 RVU budget neutrality factor: 1.00046 |
conversion factors listed | 2014 RVU rescaling adjustment factor: 1.04718 |
below) | 2014 Annual increase in the MEI: 1.008 |
2014 Cumulative adjustment factor: 1.0638 | |
For anesthesia services: | |
2014 Total RVS adjustment factor: 1.0291 | |
2014 RVU budget neutrality factor: 1.00046 | |
2014 RVU rescaling adjustment factor: 1.04718 | |
2014 anesthesia practice expense adjustment factor: 0.9823 | |
2014 Annual increase in the MEI: 1.008 | |
2014 Cumulative adjustment factor: 1.0449 | |
Anesthesia Base Units by CPT Code | 2014anesBASEfin |
California-Specific Codes | WC001 -- Not reimbursable |
WC002 -- $11.91 | |
WC003 -- $38.68 for first page | |
$23.80 each additional page. Maximum of six pages absent mutual agreement ($157.68) | |
WC004 -- $38.68 for first page | |
$23.80 each additional page. Maximum of seven pages absent mutual agreement ($181.48) | |
WC005 -- $38.68 for first page, $23.80 each additional page. Maximum of six pages absent mutual agreement ($157.68) | |
WC007 -- $38.68 for first page | |
$23.80 each additional page. Maximum of six pages absent mutual agreement ($157.68) | |
WC008 -- $10.26 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC009 -- $10.26 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC010 -- $5.13 per x-ray | |
WC011 -- $10.26 per scan | |
WC012 -- No Fee Prescribed/Non Reimbursable absent agreement | |
CCI Edits: | For services rendered on or after 1/1/2014, use: |
Medically Unlikely Edits: | “Practitioner Services MUE Table -- Updated 10/1/2013.” |
For services rendered on or after 1/23/2014, use: | |
“Practitioner Services MUE Table -- Updated 1/1/2014.” | |
For services rendered on or after 4/1/2014, use: | |
“Practitioner Services MUE Table -- Updated 4/1/2014.” | |
For services rendered on or after 7/1/2014, use: | |
“Practitioner Services MUE Table -- Updated 7/1/2014.” | |
For services rendered on or after 10/1/2014, use: | |
“Practitioner Services MUE Table -- Updated 10/1/2014.” | |
Copies of the MUE Tables are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
CMS posts only the most recent version of the Practitioner Services MUE Table on the web at: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html . | |
CCI Edits: | NCCI Policy Manual for Medicare Services -- Effective January 1, 2014 [ZIP, 749KB] |
National Correct Coding Initiative Policy Manual | Copy of the 1/1/2014 Manual is posted on the DWC website: |
for Medicare Services | http://www.dir.ca.gov/dwc/OMFS9904.htm |
CCI Edits: | For services rendered on or after January 1, 2014: |
Physician CCI Edits | Physician CCI Edits v19.3 (819,852 records). The last row contains edit column 1 = 39599 and column 2 = 49570 |
Physician CCI Edits v19.3 (710,236 records). The first row contains edit column 1 = 40490 and column 2 = C8950 | |
For services rendered on or after April 15, 2014: | |
Physician CCI Edits v20.1 effective April 1, 2014 (851,137 records). The last row contains edit | |
column 1 = 39599 and column 2 = 49570 | |
Physician CCI Edits v20.1 effective April 1, 2014 (744,393 records). The first row contains edit | |
column 1 = 40490 and column 2 = C8950 | |
For services rendered on or after July 1, 2014: | |
Physician CCI Edits v20.2 effective July 1, 2014 (863,712 records). The last row contains edit | |
column 1 = 39599 and column 2 = 49570 | |
Physician CCI Edits v20.2 effective July 1, 2014 (752,547 records). The first row contains edit | |
column 1 = 40490 and column 2 = C8950 | |
For services rendered on or after October 1, 2014: | |
Physician CCI Edits v20.3 effective October 1, 2014 (864,930 records). The last row contains edit | |
column 1 = 39599 and column 2 = 49570 | |
Physician CCI Edits v20.3 effective October 1, 2014 (756,576 records). The first row contains edit | |
column 1 = 40490 and column 2 = C8950 | |
CMS' Medicare National | For services rendered on or after January 1, 2014: |
Physician Fee Schedule | RVU14A [Zip] |
Relative Value File [Zip] | • RVUPUF14 (Excluding Attachment A) |
• PPRRVU14_V1219 | |
• OPPSCAP_V1219 | |
Excluding: | |
14LOCCO | |
ANES 2014_V0103 | |
CY 2014 GPCI _12172013 | |
For services rendered on or after April 15, 2014: | |
RVU14B [Zip] | |
• RVUPUF14 (Excluding Attachment A) | |
• PPRRVU14_V0324 | |
• OPPSCAP_V0324 | |
Excluding: | |
14LOCCO | |
ANES_2014_V0103 | |
CY 2014 GPCI_12172013 | |
For services rendered on or after July 1, 2014: | |
RVU14C [Zip 3MB] | |
• RVUPUF14 (Excluding Attachment A) | |
• PPRRVU14_V0515 | |
• OPPSCAP_V0515 | |
Excluding: | |
14LOCCO | |
ANES 2014_V0103 | |
CY 2014 GPCI_12172013 | |
For services rendered on or after October 1, 2014: | |
RVU14D [Zip 3MB] | |
• RVUPUF14 (Excluding Attachment A) | |
• PPRRVU14_V0815_v4 | |
• OPPSCAP_V0815 | |
Excluding: | |
14LOCCO | |
ANES 2014_V0103 | |
CY 2014 GPCI_12172013 | |
CMS Pub 100-04 | For services rendered on or after 1/1/2014, use: |
Medicare Claims | Transmittal 2837 (Change Request 8523) |
Processing: Casting and Splint Supplies | For services rendered on or after 4/1/2014, use: |
the OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule | |
applicable to the date of service | |
Conversion Factors adjusted | Anesthesia Conversion Factor: $33.8190 |
for MEI and Relative Value | Surgery Conversion Factor: $55.2913 |
Scale adjustment factor, | Radiology Conversion Factor: $53.1039 |
if any | Other Services Conversion Factor: $38.3542 |
Current Procedural | CPT 2014 |
Terminology (CPT®) | https://commerce.ama-assn.org/store/ |
Current Procedural | Do not use CPT codes: |
Terminology | 27215 (Use G0412 and Surgery CF) |
CPT codes that shall not | 27216 (Use G0413 and Surgery CF) |
be used | 27217 (Use G0414 and Surgery CF) |
27218 (Use G0415 and Surgery CF) | |
76140 (see § 9789.17.2) | |
80100 through 80104 (see clinical lab fee schedule, § 9789.50) | |
90889 (See § 9789.14. Use code WC005 code) | |
97014 (Use G0283 and Other Services CF) | |
99075 (see Medical-Legal fee schedule, § 9795) | |
99080 (see § 9789.14) | |
99241 through 99245 (see § 9789.12.12) | |
99251 through 99255 (see § 9789.12.12) | |
99455 and 99456. | |
Diagnostic Cardiovascular | For services rendered on or after January 1, 2014: |
Procedure CPT codes | RVU14A, PPRRVU14_V1219, Number “6” in Column labeled “Mult Proc” (Modifier 51) also |
subject to the MPPR | Addendum I, Diagnostic Cardiovascular Services Subject to The Multiple Procedure Payment |
Reduction (MPPR) CY 2014 CMS 1600 FC: | |
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-FC.html?DLPage=1&DLSort=3&DLSortDir=descending | |
For services rendered on or after April 15, 2014: | |
RVU14B, PPRRVU14_V0324, Number “6” in Column labeled “Mult Proc” (Modifier 51) also | |
Addendum I, Diagnostic Cardiovascular Services Subject to The Multiple Procedure Payment | |
Reduction (MPPR) CY 2014 CMS 1600 FC | |
For services rendered on or after July 1, 2014: | |
RVU14C, PPRRVU14_V0515, Number “6” in Column labeled “Mult Proc” (Modifier 51) also | |
Addendum I, Diagnostic Cardiovascular Services Subject to The Multiple Procedure Payment | |
Reduction (MPPR) CY 2014 CMS 1600 FC | |
For services rendered on or after October 1, 2014: | |
RVU14D, PPRRVU14_V0815_v4, Number “6” in | |
Column labeled “Mult Proc” (Modifier 51) also Addendum I, Diagnostic Cardiovascular Services Subject | |
to The Multiple Procedure Payment Reduction (MPPR) CY 2014 CMS 1600 FC | |
Diagnostic Imaging Family | For services rendered on or after January 1, 2014: |
Indicator Description | National Physician Fee Schedule Relative Value File Calendar Year 2014 |
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU14A.html?DLPage=1&DLSort=0&DLSortDir=descending | |
RVUPUF14 (PDF document) | |
For services rendered on or after April 15, 2014: | |
RVU14B, PPRRVU14_V0324, RVUPUF14 (PDF document) | |
For services rendered on or after July 1, 2014: | |
RVU14C, PPRRVU14_V0515, RVUPUF14 (PDF document) | |
For services rendered on or after October 1, 2014: | |
RVU14D, PPRRVU14_V0815_v4, RVUPUF14 (PDF document) | |
Diagnostic Imaging Family | For services rendered on or after January 1, 2014: |
Indicator for Procedure | RVU14A, PPRRVU14_V1219, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also |
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction | |
(MPPR) CY2014 CMS 1600 FC | |
For services rendered on or after April 15, 2014: | |
RVU14B, PPRRVU14_V0324, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also | |
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction | |
(MPPR) CY2014 CMS 1600 FC | |
For services rendered on or after July 1, 2014: | |
RVU14C, PPRRVU14_V0515, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also | |
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction | |
(MPPR) CY2014 CMS 1600 FC | |
For services rendered on or after October 1, 2014: | |
RVU14D, PPRRVU14_V0815_v4, column AB, labeled, “Diagnostic Imaging Family Indicator”. Also | |
Addendum F, Diagnostic Imaging Service Subject to the Multiple Procedure Payment Reduction | |
(MPPR) CY2014 CMS 1600 FC | |
DWC Pharmaceutical | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
Fee Schedule | |
Geographic Health | 2014 Primary Care HPSA [ZIP, 97KB] |
Professional | |
Shortage Area zip code | 2014 Mental Health HPSA [ZIP, 222KB] |
data files | |
Health Resources and | |
Services Administration: | |
Geographic HPSA shortage | |
area query | |
(By State & County) | http://hpsafind.hrsa.gov/ |
(By Address) | http://datawarehouse.hrsa.gov/geoHPSAAdvisor/GeographicHPSAAdvisor.aspx |
Incident To Codes | For services rendered on or after January 1, 2014: |
RVU14A, PPRRVU14_V1219, with PC/TC indicator number “5” | |
For services rendered on or after April 15, 2014: | |
RVU14B, PPRRVU14_V0324, with PC/TC indicator number “5” | |
For services rendered on or after July 1, 2014: | |
RVU14C, PPRRVU14_V0515, with PC/TC indicator number “5” | |
For services rendered on or after October 1, 2014: | |
RVU14D, PPRRVU14_V0815_v4, with PC/TC indicator number “5” | |
Medi-Cal Rates -- DHCS | For services rendered on or after 1/1/2014, use: |
Medi-Cal Rates file -- Updated 12/15/2013 | |
For services rendered on or after 1/23/2014, use: | |
Medi-Cal Rates file -- Updated 1/15/2014 | |
For services rendered on or after 2/15/2014, use: | |
Medi-Cal Rates file -- Updated 2/15/2014 | |
For services rendered on or after 3/15/2014, use: | |
Medi-Cal Rates file -- Updated 3/15/2014 | |
For services rendered on or after 6/15/2014, use: | |
Medi-Cal Rates file -- Updated 6/15/2014 | |
For services rendered on or after 7/15/2014, use: | |
Medi-Cal Rates file -- Updated 7/15/2014 | |
For services rendered on or after 8/15/2014, use: | |
Medi-Cal Rates file -- Updated 8/15/2014 | |
For services rendered on or after 9/15/2014, use: | |
Medi-Cal Rates file -- Updated 9/15/2014 | |
For services rendered on or after 10/15/2014, use: | |
Medi-Cal Rates file -- Updated 10/15/2014 | |
For services rendered on or after 11/15/2014, use: | |
Medi-Cal Rates file -- Updated 11/15/2014 | |
For services rendered on or after 12/15/2014, use: | |
Medi-Cal Rates file -- Updated 12/15/2014 | |
For services rendered on or after 1/15/2015, use: | |
Medi-Cal Rates file -- Updated 1/15/2015 | |
For services rendered on or after 2/15/2015, use: | |
Medi-Cal Rates file -- Updated 2/15/2015 | |
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
Ophthalmology Procedure | For services rendered on or after January 1, 2014: |
CPT codes subject to | RVU14A, PPRRVU14_V1219, Number “7” in Column labeled “Multiple Procedure” (Modifier 51). Also |
the MPPR | Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction |
(MPPR) CY 2014 CMS 1600 FC | |
For services rendered on or after April 15, 2014: | |
RVU14B, PPRRVU14_V0324, Number “7” in Column labeled “Multiple Procedure” (Modifier 51). Also | |
Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction | |
(MPPR) CY 2014 CMS 1600 FC | |
For services rendered on or after July 1, 2014: | |
RVU14C, PPRRVU14_V0515, Number “7” in Column labeled “Multiple Procedure” (Modifier 51). Also | |
Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction | |
(MPPR) CY 2014 CMS 1600 FC | |
For services rendered on or after October 1, 2014: | |
RVU14D, PPRRVU14_V0815_v4, Number “7” in Column labeled “Multiple Procedure” (Modifier 51). Also | |
Addendum J, Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction | |
(MPPR) CY 2014 CMS 1600 FC | |
Physical Therapy Multiple | For services rendered on or after January 1, 2014: |
Procedure Payment | RVU14A, PPRRVU14_V1219, Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately |
Reduction: “Always | Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) CY |
Therapy” Codes; and | 2014 CMS 1600 FC |
Acupuncture and Chiropractic Codes | In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 |
For services rendered on or after April 15, 2014: | |
RVU14B, PPRRVU14_V0324 , Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately | |
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) | |
CY 2014 CMS 1600 FC | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after July 1, 2014: | |
RVU14C, PPRRVU14_V0515 , Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately | |
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) CY | |
2014 CMS 1600 FC | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after October 1, 2014: | |
RVU14D, PPRRVU14_V0815_v4 , Number “5” in Column labeled “Mult Proc”. Also Addendum H, Separately | |
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) CY | |
2014 CMS 1600 FC | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
Physician Time | CY 2014 PFS Physician Time [ZIP, 504KB] |
Radiology Diagnostic | For services rendered on or after January 1, 2014: |
Imaging Multiple | RVU14A, PPRRVU14_V1219, number “4” in column S, labeled, “Mult Proc” |
Procedures | |
For services rendered on or after April 15, 2014: | |
RVU14B, PPRRVU14_V0324 , number “4” in column S, labeled, “Mult Proc” | |
For services rendered on or after July 1, 2014: | |
RVU14C, PPRRVU14_V0515 , number “4” in column S, labeled, “Mult Proc” | |
For services rendered on or after October 1, 2014: | |
RVU14D, PPRRVU14_V0815_v4 , number “4” in | |
column S, labeled, “Mult Proc” | |
Statewide GAFs | Average Statewide Work GAF: 1.040 |
(Other than anesthesia) | Average Statewide Practice Expense GAF: 1.1606 |
Average Statewide Malpractice Expense GAF: 0.6636 | |
Statewide GAF (Anesthesia) | Average Statewide Anesthesia GAF: 1.0313 |
The 1995 Documentation | https://www.cms.gov/Outreach-and-Education/Medicare-Learning- |
Guidelines for Evaluation & | Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf |
Management Services | |
The 1997 Documentation | https://www.cms.gov/Outreach-and-Education/Medicare-Learning- |
Guidelines for Evaluation | Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. |
and Management Services |
Document/Data | Services Rendered On or After March 1, 2015 & Mid-year Updates |
---|---|
Adjustment Factors | For all services other than anesthesia: |
(These factors have been | 2015 Cumulative Relative Value Scale adjustment factor: 1.0703 |
incorporated into the | [2015 annual adjustment factor x 2014 cumulative adjustment factor = 2015 cumulative adjustment |
conversion factors listed | factor (1.006 x 1.0638 = 1.0703)] |
below) | 2015 RVS adjustment factor†: 0.9981 |
2015 Annual increase in the MEI: 1.008 | |
2015 Annual adjustment factor: 1.006 (0.9981 x 1.008) | |
For anesthesia services: | |
2015 Anesthesia cumulative adjustment factor: 1.0461 | |
[2015 anesthesia annual adjustment factor x 2014 anesthesia cumulative adjustment factor = 2015 | |
cumulative adjustment factor (1.001 x 1.0449 = 1.0461)] | |
2015 Total RVS adjustment factor†: 0.9932 | |
2015 RVU budget neutrality factor: 0.9981 | |
2015 Anesthesia practice expense adjustment factor: 0.99506 | |
2015 Annual increase in the MEI: 1.008 | |
2015 Anesthesia annual adjustment factor: 1.001 | |
[BN RVU x Anesthesia PE Adjustment x MEI = (0.9981 x 0.99506 x 1.008 ) = 1.001] | |
†RVS adjustment factor for 2015 is 1) the RVU budget neutrality adjustment factor for “all services other than anesthesia”; and 2) the product of RVU budget neutrality adjustment factor and the anesthesia practice expense adjustment factor for anesthesia services. | |
Anesthesia Base Units by | 2014anesBASEfin |
CPT Code | |
California-Specific Codes | WC001 -- Not reimbursable |
WC002 -- $ 12.01 | |
WC003 -- $38.99 for first page | |
$23.99 each additional page. Maximum of six pages absent mutual agreement ($158.94) | |
WC004 -- $38.99 for first page | |
$23.99 each additional page. Maximum of seven pages absent mutual agreement ($182.93) | |
WC005 -- $38.99 for first page, $23.99 each additional page. Maximum of six pages absent mutual agreement ($158.94) | |
WC007 -- $38.99 for first page | |
$23.99 each additional page. Maximum of six pages absent mutual agreement ($158.94) | |
WC008 -- $10.34 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC009 -- $10.34 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC010 -- $5.17 per x-ray | |
WC011 -- $10.34 per scan | |
WC012 -- No Fee Prescribed / Non Reimbursable absent agreement | |
CCI Edits: | For services rendered on or after March 1, 2015, use: |
Medically Unlikely Edits | “Practitioner Services MUE Table -- Effective 1/1/2015.” |
For services rendered on or after April 1, 2015, use: | |
“Practitioner Services MUE Table -- Effective 4/1/2015.” | |
For services rendered on or after July 1, 2015, use: | |
“Practitioner Services MUE Table -- Effective 7/1/2015.” | |
For services rendered on or after October 1, 2015, use: | |
“Practitioner Services MUE Table -- Effective 10/1/2015.” | |
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm | |
CMS posts only the most recent version of the Practitioner Services MUE Table on the web at: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html . | |
CCI Edits: | For services rendered on or after March 1, 2015: |
National Correct Coding | “NCCI Policy Manual for Medicare Services -- Effective January 1, 2015 [ZIP, 1MB]” |
Initiative Policy Manual for Medicare Services | Copy of the 2015 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7 |
CCI Edits: | For services rendered on or after March 1, 2015: |
Physician CCI Edits | Physician CCI Edits v21.0 effective January 1, 2015 (898,800 records). The last row contains edit |
(Practitioner PTP Edits) | column 1 = 39599 and column 2 = 49570 |
Physician CCI Edits v21.0 effective January 1, 2015 (787,357 records). The first row contains edit | |
column 1 = 40490 and column 2 = C8950 | |
For services rendered on or after April 1, 2015: | |
Practitioner PTP Edits v21.1 effective April 1, 2015 (899,747 records ). The last row contains edits | |
column 1 = 39599 and column 2 = 49570 | |
Practitioner PTP Edits v21.1 effective April 1, 2015 (787,520 records ). The first row contains edits | |
column 1 = 40490 and column 2 = C8950 | |
For services rendered on or after July 1, 2015: | |
Practitioner PTP Edits v21.2 effective July 1, 2015 (872,404 records ). The last row contains edits | |
column 1 = 39599 and column 2 = 49570 | |
Practitioner PTP Edits v21.2 effective July 1, 2015 (821,537 records ). The first row contains edits | |
column 1 = 40490 and column 2 = 00170 | |
For services rendered on or after October 1, 2015: | |
Practitioner PTP Edits v21.3 effective October 1, 2015 (880,855 records). The last row contains edits | |
column 1 = 39599 and column 2 = 49570 | |
Practitioner PTP Edits v21.3 effective October 1, 2015 (832,093 records). The first row contains edits | |
column 1 = 40490 and column 2 = 00170 | |
Access the Physician CCI Edits on the CMS website: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html | |
Note: the Physician CCI Edits excel file maintained by CMS contains effective date and deletion date (if any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website, and covers all time periods. | |
CMS' Medicare National | For services rendered on or after March 1, 2015: |
Physician Fee Schedule | RVU15A (Updated 01/08/15) [ZIP, 2MB] |
Relative Value File [Zip] | • RVUPUF15 (Excluding Attachment A) |
• PPRRVU15_V1223c | |
• OPPSCAP_V1223 | |
Excluding: | |
15LOCCO | |
ANES 2015_V122314 | |
CY2015_GPCIs | |
For services rendered on or after May 1, 2015: | |
RVU15B [ZIP, 3MB] | |
• RVUPUF15 (Excluding Attachment A) | |
• PPRRVU15_V0213_Current | |
• OPPSCAP_V0217 | |
Excluding: | |
15LOCCO | |
Anes_2015_122314 | |
Anes_Conv_122314_fmt | |
CY2015_GPCIs | |
For services rendered on or after July 1, 2015: | |
RVU15C [ZIP, 5MB] (Except the 0.5% update is not adopted) | |
• RVUPUF15 (Excluding Attachment A) | |
• PPRRVU15_UP05_V0622 | |
• OPPSCAP_UP05_V0619 | |
Excluding: | |
15LOCCO | |
Anes_2015_122314 | |
ANES_2015_UP05_V0701 | |
CY2015_GPCIs | |
PPRRVU15_UP0.V0515 | |
OPPSCAP_UP0_V0515 | |
For services rendered on or after October 1, 2015: | |
RVU15D [ZIP, 5MB] (Except the 0.5% update is not adopted) | |
• RVUPUF15 (Excluding Attachment A) | |
• PPRRVU15_OCT05_V1001 | |
• OPPSCAP_UP05_V0815 | |
Excluding: | |
15LOCCO | |
Anes_2015_122314 | |
ANES_2015_UP05_V0701 | |
CY2015_GPCIs | |
OPPSCAP_UP0_V0815 | |
PPRRVU15_OCT_V1001 | |
Conversion Factors adjusted | Anesthesia Conversion Factor: $31.5290 |
for MEI and Relative Value | Surgery Conversion Factor: $51.6570 |
Scale adjustment factor | Radiology Conversion Factor: $50.1900 |
Other Services Conversion Factor: $40.2970 | |
Current Procedural | CPT 2015 |
Terminology (CPT®) | https://commerce.ama-assn.org/store/ |
Current Procedural | Do not use CPT codes: |
Terminology | 27215 (Use G0412 and Surgery CF) |
CPT codes that shall not | 27216 (Use G0413 and Surgery CF) |
be used | 27217 (Use G0414 and Surgery CF) |
Document/Data | Services Rendered On or After March 1, 2015 & Mid-year Updates |
---|---|
27218 (Use G0415 and Surgery CF) | |
76140 (see § 9789.17.2) | |
90889 (See § 9789.14. Use code WC005 code) | |
97014 (Use G0283 and Other Services CF) | |
99075 (see Medical-Legal fee schedule, § 9795) | |
99080 (see § 9789.14) | |
99241 through 99245 (see § 9789.12.12) | |
99251 through 99255 (see § 9789.12.12) | |
99455 and 99456. | |
Diagnostic Cardiovascular | For services rendered on or after March 1, 2015: |
Procedure CPT codes | RVU15A, PPRRVU15_V1223c, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed |
subject to the MPPR | in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the document CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure Payment Reduction (MPPR) |
For services rendered on or after May 1, 2015: | |
RVU15B, PPRRVU15_V0213_Current, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the document CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after July 1, 2015: | |
RVU15C, PPRRVU15_UP05_V0622, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the document CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after October 1, 2015: | |
RVU15D, PPRRVU15_OCT05_V1001, Number “6” in Column labeled “Mult Proc” (Modifier 51), also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 44KB], in the document CY_2015_PFS_1612-F_ Diagnostic Cardiovascular Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
Diagnostic Imaging Family | For services rendered on or after March 1, 2015: |
Indicator Description | Diagnostic Imaging Family Indicator: |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU15A, RVUPUF15 (PDF document) | |
For services rendered on or after May 1, 2015: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU15B, RVUPUF15 (PDF document) | |
For services rendered on or after July 1, 2015: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU15C, RVUPUF15 (PDF document) | |
For services rendered on or after October 1, 2015: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU15D, RVUPUF15 (PDF document) | |
Diagnostic Imaging Family | For services rendered on or after March 1, 2015: |
Procedures Subject to the | RVU15A, PPRRVU15_V1223c, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”, |
MPPR | also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) |
For services rendered on or after May 1, 2015: | |
RVU15B, PPRRVU15_V0213_Current, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after July 1, 2015: | |
RVU15C, PPRRVU15_UP05_V0622, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after October 1, 2015: | |
RVU15D, PPRRVU15_OCT05_V1001, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
Diagnostic Imaging | For services rendered on or after March 1, 2015: |
Multiple Procedures | RVU15A, PPRRVU15_V1223c, number “4” in column S, labeled, “Mult Proc”, also listed in CY |
Subject to the MPPR | 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document |
CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after May 1, 2015: | |
RVU15B, PPRRVU15_V0213_Current, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after July 1, 2015: | |
RVU15C, PPRRVU15_UP05_V0622, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after October 1, 2015: | |
RVU15D, PPRRVU15_OCT05_V1001, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F_Diagnostic Imaging Services Subject To the Multiple Procedure Payment Reduction (MPPR) | |
DWC Pharmaceutical Fee | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
Schedule | |
Geographic Health | 2015 Primary Care HPSA [ZIP, 88KB] |
Professional Shortage | 2015 Mental Health HPSA [ZIP, 185KB] |
Area zip code data files | |
Health Resources and Services Administration: | |
Geographic HPSA shortage area query | |
(By State & County) | http://hpsafind.hrsa.gov/ |
(By Address) | http://datawarehouse.hrsa.gov/geoHPSAAdvisor/GeographicHPSAAdvisor.aspx |
Incident To Codes | For services rendered on or after March 1, 2015: |
RVU15A, PPRRVU15_V1223c, with PC/TC indicator number “5” | |
For services rendered on or after May 1, 2015: | |
RVU15B, PPRRVU15_V0213_Current, with PC/TC indicator number “5” | |
For services rendered on or after July 1, 2015: | |
RVU15C, PPRRVU15_UP05_V0622, with PC/TC indicator number “5” | |
For services rendered on or after October 1, 2015: | |
RVU15D, PPRRVU15_OCT05_V1001, with PC/TC indicator number “5” | |
Medi-Cal Rates - DHCS | Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service. |
For services rendered on or after March 1, 2015, use: | |
Medi-Cal Rates file -- Updated 2/15/2015 | |
For services rendered on or after March 15, 2015, use: | |
Medi-Cal Rates file -- Updated 3/15/2015 | |
For services rendered on or after April 15, 2015, use: | |
Medi-Cal Rates file -- Updated 4/15/2015 | |
For services rendered on or after May 15, 2015, use: | |
Medi-Cal Rates file -- Updated 5/15/2015 | |
For services rendered on or after June 15, 2015, use: | |
Medi-Cal Rates file - Updated 6/15/2015 | |
For services rendered on or after July 15, 2015, use: | |
Medi-Cal Rates file -- Updated 7/15/2015 | |
For services rendered on or after August 15, 2015, use: | |
Medi-Cal Rates file -- Updated 8/15/2015 | |
For services rendered on or after September 15, 2015, use: | |
Medi-Cal Rates file -- Updated 9/15/2015 | |
For services rendered on or after October 15, 2015, use: | |
Medi-Cal Rates file -- Updated 10/15/2015 | |
For services rendered on or after November 15, 2015, use: | |
Medi-Cal Rates file -- Updated 11/15/2015 | |
For services rendered on or after December 15, 2015, use: | |
Medi-Cal Rates file -- Updated 12/15/2015 | |
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
Ophthalmology Procedure | For services rendered on or after March 1, 2015: |
CPT codes subject to the | RVU15A, PPRRVU15_V1223c, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also listed |
MPPR | in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction (MPPR) |
For services rendered on or after May 1, 2015: | |
RVU15B, PPRRVU15_V0213_Current, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after July 1, 2015: | |
RVU15C, PPRRVU15_UP05_V0622, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction (MPPR) | |
For services rendered on or after October 1, 2015: | |
RVU15D, PPRRVU15_OCT05_V1001, Number “7” in Column labeled “Mult Proc” (Modifier 51). Also listed in CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB], in the document CY_2015_PFS_1612-F Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction (MPPR) | |
Physical Therapy Multiple | For services rendered on or after March 1, 2015: |
Procedure Payment | RVU15A, PPRRVU15_V1223c, Number “5” in Column labeled “Mult Proc”. Also listed in the CY |
Reduction: “Always | 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the |
Therapy” Codes; and | document CY_2015_PFS_1612-F Separately Payable Always Therapy Services Subject to the Multiple |
Acupuncture and | Procedure Payment Reduction (MPPR) |
Chiropractic Codes | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after May 1, 2015: | |
RVU15B, PPRRVU15_V0213_Current, Number “5” in Column labeled “Mult Proc”. Also listed in the CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the document CY_2015_PFS_1612-F Separately Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after July 1, 2015: | |
RVU15C, PPRRVU15_UP05_V0622, Number “5” in Column labeled “Mult Proc”. Also listed in the CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the document CY_2015_PFS_1612-F Separately Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after October 1, 2015: | |
RVU15D, PPRRVU15_OCT05_V1001, Number “5” in Column labeled “Mult Proc”. Also listed in the CY 2015 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 44KB] in the document CY_2015_PFS_1612-F Separately Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR) | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
Physician Time | CY 2015 PFS Final Rule Physician Time Updated 01/20/15 [ZIP 478KB] |
Statewide GAFs (Other | Average Statewide Work GAF: 1.0420 |
than anesthesia) | Average Statewide Practice Expense GAF: 1.1621 |
Average Statewide Malpractice Expense GAF: 0.7388 | |
Statewide GAF (Anesthesia) | Average Statewide Anesthesia GAF: 1.0391 |
Splints and Casting Supplies | For services rendered on or after March 1, 2015, use: |
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. | |
The 1995 Documentation | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/ |
Guidelines for Evaluation | Downloads/95Docguidelines.pdf |
& Management Services | |
The 1997 Documentation | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/ |
Guidelines for Evaluation | Downloads/97Docguidelines.pdf. |
and Management Services |
Document/Data | Services Rendered On or After January 1, 2016 & Mid-year Updates |
---|---|
Adjustment Factors (These | For services rendered on or after January 1, 2016: |
factors have been | For all services other than anesthesia |
incorporated into the | 2016 Cumulative adjustment factor: 1.0818 |
conversion factors listed | 2016 RVU budget neutrality adjustment factor: 0.9998 |
below) | 2016 Annual increase in the MEI: 1.011 |
2015 Cumulative “other than anesthesia” adjustment 1.0703 | |
For anesthesia services: | |
2016 Cumulative anesthesia adjustment factor: 1.0527 | |
2016 RVU budget neutrality adjustment factor: 0.9998 | |
2016 Anesthesia Practice Expense and Malpractice adjustment factor: 0.99555 | |
2016 Annual increase in the MEI: 1.011 | |
2015 Cumulative anesthesia adjustment: 1.0461 | |
For services rendered on or after April 1, 2016: | |
For all services other than anesthesia: | |
2016 Cumulative adjustment factor: 1.0812 | |
2016 RVU budget neutrality adjustment factor: 0.99924 | |
2016 Annual increase in the MEI: 1.011 | |
2015 Cumulative “other than anesthesia” adjustment 1.0703 | |
For anesthesia services: | |
2016 Cumulative anesthesia adjustment factor: 1.0317 | |
2016 RVU budget neutrality adjustment factor: 0.99924 | |
2016 Anesthesia Practice Expense and Malpractice adjustment factor: 0.97628 | |
2016 Annual increase in the MEI: 1.011 | |
2015 Cumulative anesthesia adjustment: 1.0461 | |
Anesthesia Base Units by | 2014anesBASEfin |
CPT Code | |
California-Specific Codes | WC001 -- Not reimbursable |
WC002 -- $ 12.14 | |
WC003 -- $39.42 for first page | |
$24.25 each additional page. Maximum of six pages absent mutual agreement ($160.69) | |
WC004 -- $39.42 for first page | |
$24.25 each additional page. Maximum of seven pages absent mutual agreement ($184.94) | |
WC005 -- $39.42 for first page, $24.25 each additional page. Maximum of six pages absent | |
mutual agreement ($160.69) | |
WC007 -- $39.42 for first page | |
$24.25 each additional page. Maximum of six pages absent mutual agreement ($160.69) | |
WC008 -- $10.45 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC009 -- $10.45 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC010 -- $5.23 per x-ray | |
WC011 -- $10.45 per scan | |
WC012 -- No Fee Prescribed / Non Reimbursable absent agreement | |
CCI Edits: | For services rendered on or after January 1, 2016, use: |
Medically Unlikely Edits | “Practitioner Services MUE Table -- Effective 1/1/2016.” |
For services rendered on or after April 1, 2016, use: | |
“Practitioner Services MUE Table -- Effective 4/1/2016.” | |
For services rendered on or after July 1, 2016, use: | |
“Practitioner Services MUE Table -- Effective 7/1/2016.” | |
For services rendered on or after October 1, 2016, use: | |
“Practitioner Services MUE Table -- Effective 10/1/2016.” | |
Copies of the MUE Tables are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
CMS posts only the most recent version of the Practitioner Services MUE Table on the web at: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html | |
CCI Edits: | For services rendered on or after January 1, 2016: |
National Correct Coding | “NCCI Policy Manual for Medicare Services -- Effective January 1, 2016 [ZIP, 761MB]” |
Initiative Policy Manual for Medicare Services | Copy of the 2016 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7 |
CCI Edits: | |
Physician CCI Edits | For services rendered on or after January 1, 2016: |
(Practitioner PTP Edits) | |
Practitioner PTP Edits v22.0 effective January 1, 2016 (903,287 records). The last row contains edits | |
column 1 = 39599 and column 2 = 49570 | |
Practitioner PTP Edits v22.0 effective January 1, 2016 (866,823 records). The first row contains edits | |
column 1 = 40490 and column 2 = 00170 | |
For services rendered on or after April 1, 2016: | |
Practitioner PTP Edits v22.1 effective April 1, 2016 (914,985 records). The last row contains edits | |
column 1 = 39599 and column 2 = 49570 | |
Practitioner PTP Edits v22.1 effective April 1, 2016 (877,109 records). The first row contains edits | |
column 1 = 40490 and column 2 = 00170 | |
For services rendered on or after July 1, 2016: | |
Practitioner PTP Edits v22.2 effective July 1, 2016 (915,436 records). The last row contains edits | |
column 1 = 39599 and column 2 = 49570 | |
Practitioner PTP Edits v22.2 effective July 1, 2016 (877,847 records). The first row contains edits | |
column 1 = 40490 and column 2 = 00170 | |
For services rendered on or after October 1, 2016: | |
Practitioner PTP Edits v22.3 effective October 1, 2016 (668,511 records) 0001M/36591 - 29999/G0354 | |
Practitioner PTP Edits v22.3 effective October 1, 2016 (498,018 records) 30000/0213T - 49999/49570 | |
Practitioner PTP Edits v22.3 effective October 1, 2016 (489,682 records) 50010/0213T - 79999/90784 | |
Practitioner PTP Edits v22.3 effective October 1, 2016 (179,162 records) 80003/80002 - R0075/R0070 | |
Access the Physician CCI Edits on the CMS website: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html | |
Note: the Physician CCI Edits excel file maintained by CMS contains effective date and deletion date (if any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website, and covers all time periods. | |
CMS' Medicare National | For services rendered on or after January 1, 2016: |
Physician Fee Schedule | RVU16A (Released January 2016) [ZIP, 3MB] |
Relative Value File [Zip] | • RVUPUF16 (Excluding Attachment A) |
• PPRRVU16_V0122 | |
• OPPSCAP_V0105 | |
Excluding: | |
16LOCCO | |
ANES_V0105 | |
CY2016_GPCIs | |
For services rendered on or after April 1, 2016: | |
RVU16B (April 2016 release) [ZIP, 3MB] | |
• RVUPUF16 (Excluding Attachment A) | |
• PPRRVU16_April_V0202 | |
• OPPSCAP_V0215 | |
Excluding: | |
16LOCCO | |
ANES_V0105 | |
CY2016_GPCIs | |
For services rendered on or after July 1, 2016: | |
RVU16C (July 2016 release) [ZIP, 3MB] | |
• RVUPUF16 (Excluding Attachment A) | |
• PPRRVU16_V0517 | |
• OPPSCAP_V0515 | |
Excluding: | |
16LOCCO | |
ANES_V0105 | |
CY2016_GPCIs | |
For services rendered on or after October 1, 2016: | |
RVU16D [ZIP, 3MB] | |
• RVUPUF16 (Excluding Attachment A) | |
• PPRRVU16_V0804 | |
• OPPSCAP_V0815 | |
Excluding: | |
16LOCCO | |
ANES_V0105 | |
CY2016_GPCIs | |
Conversion Factors adjusted | For services rendered on or after January 1, 2016: |
for MEI and Relative Value | Anesthesia Conversion Factor: $29.3852 |
Scale adjustment factor | Surgery Conversion Factor: $48.2013 |
Radiology Conversion Factor: $47.4598 | |
Other Services Conversion Factor: $42.4599 | |
For services rendered on or after April 1, 2016: | |
Anesthesia Conversion Factor: $28.8003 | |
Surgery Conversion Factor: $48.1743 | |
Radiology Conversion Factor: $47.4332 | |
Other Services Conversion Factor: $42.4361 | |
Current Procedural | CPT 2016 |
Terminology (CPT®) | https://commerce.ama-assn.org/store/ |
Current Procedural | Do not use CPT codes: |
Terminology | 27215 (Use G0412 and Surgery CF) |
CPT codes that shall not | 27216 (Use G0413 and Surgery CF) |
be used | 27217 (Use G0414 and Surgery CF) |
27218 (Use G0415 and Surgery CF) | |
76140 (see § 9789.17.2) | |
90889 (See § 9789.14. Use codeWC005 code) | |
97014 (Use G0283 and Other Services CF) | |
99075 (see Medical-Legal fee schedule, § 9795) | |
99080 (see § 9789.14) | |
99241 through 99245 (see § 9789.12.12) | |
99251 through 99255 (see § 9789.12.12) | |
99455 and 99456 | |
Diagnostic Cardiovascular | For services rendered on or after January 1, 2016: |
Procedure CPT codes | RVU16A, PPRRVU16_V0122, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed |
subject to the MPPR | in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the document CMS-1631-FC_Diagnostic Cardiovascular Services Subject to MPPR |
For services rendered on or after April 1, 2016: | |
RVU16B, PPRRVU16_April_V0202, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the document CMS-1631-FC_ Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after July 1, 2016: | |
RVU16C, PPRRVU16_V0517, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the document CMS-1631-FC_ Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after October 1, 2016: | |
RVU16D, PPRRVU16_V0804, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction Files [Zip, 39KB], in the document CMS-1631-FC_ Diagnostic Cardiovascular Services Subject to MPPR | |
Diagnostic Imaging Family | For services rendered on or after January 1, 2016: |
Indicator Description | Diagnostic Imaging Family Indicator: |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU16A, RVUPUF16 (PDF document) | |
For services rendered on or after April 1, 2016: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU16B, RVUPUF16 (PDF document) | |
For services rendered on or after July 1, 2016: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU16C, RVUPUF16 (PDF document) | |
For services rendered on or after October 1, 2016: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU16D, RVUPUF16 (PDF document) | |
Diagnostic Imaging Family | For services rendered on or after January 1, 2016: |
Procedures Subject to | RVU16A, PPRRVU16_V0122, number “88” in column AB, labeled, “Diagnostic Imaging Family |
the MPPR | Indicator”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR |
For services rendered on or after April 1, 2016: | |
RVU16B, PPRRVU16l_V0202, number “88” in column AB, lableled, “Diagnostic Imaging Family Indicator”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [ZIP, 39 KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after July 1, 2016: | |
RVU16C, PPRRVU16_V0517, number “88” in column AB, lableled, “Diagnostic Imaging Family Indicator”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [ZIP, 39 KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after October 1, 2016: | |
RVU16D, PPRRVU16_V0804, number “88” in column AB, lableled, “Diagnostic Imaging Family Indicator”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [ZIP, 39 KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR | |
Diagnostic Imaging Multiple | For services rendered on or after January 1, 2016: |
Procedures Subject to the | RVU16A, PPRRVU16_V0122, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2016 PFS |
MPPR | Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR |
For services rendered on or after April 1, 2016: | |
RVU16B, PPRRVU16_April_V0202, number “4” in column S, labled, “Mult Proc”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after July 1, 2016: | |
RVU16C, PPRRVU16_V0517, number “4” in column S, labled, “Mult Proc”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after October 1, 2016: | |
RVU16D, PPRRVU16_V0804, number “4” in column S, labled, “Mult Proc”, also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the document CMS-1631-FC_Diagnostic Imaging Services Subject to MPPR | |
DWC Pharmaceutical Fee | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
Schedule | |
Geographic Health | 2016 Primary Care HPSA [ZIP, 99KB] |
Professional Shortage | 2016 Mental Health HPSA [ZIP, 239KB] |
Area zip code data files | Access the files on the CMS website: |
https://www.cms.gov/Medicare/Medicare-Fee-for-Service- | |
Payment/HPSAPSAPhysicianBonuses/index.html?redirect=/hpsapsaphysicianbonuses/ | |
Health Resources and Services Administration: Geographic HPSA shortage area query | |
(By State & County) | http://hpsafind.hrsa.gov/ |
(By Address) | http://datawarehouse.hrsa.gov/geoHPSAAdvisor/GeographicHPSAAdvisor.aspx |
Incident To Codes | For services rendered on or after January 1, 2016: |
RVU16A, PPRRVU16_V0122, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator) | |
For services rendered on or after April 1, 2016: | |
RVU16B, PPRRVU16_April_V0202, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator) | |
For services rendered on or after July 1, 2016: | |
RVU16C, PPRRVU16_V0517, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator) | |
For services rendered on or after October 1, 2016: | |
RVU16D, PPRRVU16_V0804, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator) | |
Medi-Cal Rates - DHCS | Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service. |
For services rendered on or after January 1, 2016, use: | |
Medi-Cal Rates file -- Updated 12/15/2015 | |
For services rendered on or after January 15, 2016, use: | |
Medi-Cal Rates file -- Updated 1/15/2016 | |
For services rendered on or after February 15, 2016, use: | |
Medi-Cal Rates file -- Updated 2/15/2016 | |
For services rendered on or after March 15, 2016, use: | |
Medi-Cal Rates file -- Updated 3/15/2016 | |
For services rendered on or after April 15, 2016, use: | |
Medi-Cal Rates file -- Updated 4/15/2016 | |
For services rendered on or after May 15, 2016, use: | |
Medi-Cal Rates file -- Updated 5/15/2016 | |
For services rendered on or after June 15, 2016, use: | |
Medi-Cal Rates file -- Updated 6/15/2016 | |
For services rendered on or after July 15, 2016, use: | |
Medi-Cal Rates file -- Updated 7/15/2016 | |
For services rendered on or after August 15, 2016, use: | |
Medi-Cal Rates file -- Updated 8/15/2016 | |
For services rendered on or after September 15, 2016, use: | |
Medi-Cal Rates file -- Updated 9/15/2016 | |
For services rendered on or after October 15, 2016, use: | |
Medi-Cal Rates file -- Updated 10/15/2016 | |
For services rendered on or after November 15, 2016, use: | |
Medi-Cal Rates file -- Updated 11/15/2016 | |
For services rendered on or after December 15, 2016, use: | |
Medi-Cal Rates file -- Updated 12/15/2016 | |
For services rendered on or after January 15, 2017, use: | |
Medi-Cal Rates file -- Updated 1/15/2017 | |
For services rendered on or after February 15, 2017, use: | |
Medi-Cal Rates file -- Updated 2/15/2017 | |
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
Ophthalmology Procedure | For services rendered on or after January 1, 2016: |
CPT codes subject to the | RVU16A, PPRRVU16_V0122, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also |
MPPR | listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR |
For services rendered on or after April 1, 2016: | |
RVU16B, PPRRVU16_April_V0202, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR | |
For services rendered on or after July 1, 2016: | |
RVU16C, PPRRVU16_V0517, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR | |
For services rendered on or after October 1, 2016: | |
RVU16D, PPRRVU16_V0804, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB], in the CMS-1631-FC_Diagnostic Ophthalmology Services Subject to MPPR | |
Physical Therapy Multiple | For services rendered on or after January 1, 2016: |
Procedure Payment | RVU16A, PPRRVU16_V0122, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2016 |
Reduction: “Always | PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document |
Therapy” Codes; and | CMS-1631-FC_Separately Payable Therapy Services Subject to MPPR |
Acupuncture and | |
Chiropractic Codes | In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 |
For services rendered on or after April 1, 2016: | |
RVU16B, PPRRVU16_April_V0202, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document CMS-1631-FC_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after July 1, 2016: | |
RVU16C, PPRRVU16_V0517, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document CMS-1631-FC_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after October 1, 2016: | |
RVU16D, PPRRVU16_V0804, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2016 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 39KB] in the document CMS-1631-FC_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
Physician Time | CY 2016 PFS Final Rule Work Time [ZIP 220KB] |
Statewide GAFs (Other than | Average Statewide Work GAF: 1.0420 |
anesthesia) | Average Statewide Practice Expense GAF: 1.1621 |
Average Statewide Malpractice Expense GAF: 0.7388 | |
Statewide GAF (Anesthesia) | Average Statewide Anesthesia GAF: 1.0487 |
Splints and Casting Supplies | For services rendered on or after January 1, 2016, use: |
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. | |
The 1995 Documentation Guidelines for Evaluation & Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf |
The 1997 Documentation Guidelines for Evaluation and Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf |
Document/Data | Services Rendered On or After March 1, 2017 & Mid-year Updates |
---|---|
Adjustment Factors | For services rendered on or after March 1, 2017: |
(These factors have been | |
incorporated into the | For all services other than anesthesia: |
conversion factors listed | 2017 Cumulative adjustment factor: 1.0933 |
below) | 2017 RVU budget neutrality adjustment factor: 0.99987 |
2017 Imaging MPPR adjustment factor: 0.9993 | |
2017 Annual increase in the MEI: 1.012 | |
2016 Cumulative “other than anesthesia” adjustment: 1.0812 | |
For anesthesia services: | |
2017 Cumulative anesthesia adjustment factor: 1.0433 | |
2017 RVU budget neutrality adjustment factor: 0.99987 | |
2017 Imaging MPPR adjustment factor: 0.9993 | |
2017 Annual increase in the MEI: 1.012 | |
2016 Cumulative anesthesia adjustment: 1.0317 | |
Anesthesia Base Units by CPT Code | 2014anesBASEfin |
California-Specific Codes | WC001 -- Not reimbursable |
WC002 -- $12.29 | |
WC003 -- $39.89 for first page | |
$24.54 each additional page. Maximum of six pages absent mutual agreement ($162.59) | |
WC004 -- $39.89 for first page | |
$24.54 each additional page. Maximum of seven pages absent mutual agreement ($187.13) | |
WC005 -- $39.89 for first page, $24.54 each additional page. Maximum of six pages absent mutual agreement ($162.59) | |
WC007 -- $39.89 for first page | |
$24.54 each additional page. Maximum of six pages absent mutual agreement ($162.59) | |
WC008 -- $10.58 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC009 -- $10.58 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC010 -- $5.29 per x-ray | |
WC011 -- $10.58 per scan | |
WC012 -- No Fee Prescribed /Non Reimbursable absent agreement | |
CCI Edits: | For services rendered on or after March 1, 2017, use: |
Medically Unlikely Edits | “Practitioner Services MUE Table -- Effective 1/1/2017.” |
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm | |
For services rendered on or after April 1, 2017, use: | |
“Practitioner Services MUE Table -- Effective 4/1/2017.” | |
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm | |
For services rendered on or after July 1, 2017, use: | |
“Practitioner Services MUE Table -- Effective 7/1/2017.” | |
Copies of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm | |
For services rendered on or after October 1, 2017, use: | |
“Practitioner Services MUE Table -- Effective 10/1/2017.” | |
Copies of the MUE Tables are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
CMS posts only the most recent version of the Practitioner Services MUE Table on the web at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html | |
CCI Edits: | For services rendered on or after March 1, 2017: |
National Correct Coding | “NCCI Policy Manual for Medicare Services -- Effective January 1, 2017 [ZIP, 770KB]” |
Initiative Policy Manual for | |
Medicare Services | Copy of the 2017 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7 |
CCI Edits: | For services rendered on or after March 1, 2017: |
Physician CCI Edits | Practitioner PTP Edits v23.0 effective January 1, 2017 (422,052 records) 0001M/36591 - 24940/G0471 |
(Practitioner PTP Edits) | Practitioner PTP Edits v23.0 effective January 1, 2017 (574,135 records) 25000/01810 - 39599/49570 |
Practitioner PTP Edits v23.0 effective January 1, 2017 (436,857 records) 40490/00170 - 59897/G0347 | |
Practitioner PTP Edits v23.0 effective January 1, 2017 (501,820 records) 60000/0213T - R0075/R0070 | |
For services rendered on or after April 1, 2017: | |
Practitioner PTP Edits v23.1 effective April 1, 2017 (474,500 records) 0001M/36591 - 25931/G0471 | |
Practitioner PTP Edits v23.1 effective April 1, 2017 (502,046 records) 26010/01810 - 36909/J2001 | |
Practitioner PTP Edits v23.1 effective April 1, 2017 (495,097 records) 37140/0213T - 60650/G0471 | |
Practitioner PTP Edits v23.1 effective April 1, 2017 (501,223 records) 61000/0213T - R0075/R0070 | |
For services rendered on or after July 1, 2017: | |
Practitioner PTP Edits v23.2 effective July 1, 2017 (476,159 records) 0001M/36591 - 25931/G0471 [ZIP, 13MB] | |
Practitioner PTP Edits v23.2 effective July 1, 2017 (502,166 records) 26010/01810 - 36909/J2001 [ZIP, 13MB] | |
Practitioner PTP Edits v23.2 effective July 1, 2017 (495,291 records) 37140/0213T - 60650/G0471 [ZIP, 13MB] | |
Practitioner PTP Edits v23.2 effective July 1, 2017 (503,693 records) 61000/0213T - R0075/R0070 [ZIP, 13MB] | |
For services rendered on or after October 1, 2017: | |
Practitioner PTP Edits v23.3 effective October 1, 2017 (476,064 records) 0001M/36591 - 25931/G0471 | |
Practitioner PTP Edits v23.3 effective October 1, 2017 (502,759 records) 26010/01810 - 36909/J2001 | |
Practitioner PTP Edits v23.3 effective October 1, 2017 (495,446 records) 37140/0213T - 60650/G0471 | |
Practitioner PTP Edits v23.3 effective October 1, 2017 (504,589 records) 61000/0213T - R0075/R0070 | |
Access the Physician CCI Edits on the CMS website: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html | |
Note: the Physician CCI Edits excel file maintained by CMS contains effective date and deletion date (if any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website, and covers all time periods. | |
CMS' Medicare National | For services rendered on or after March 1, 2017: |
Physician Fee Schedule | RVU17A (January 2017 release) [ZIP, 3MB] |
Relative Value File [Zip] | • RVU17A (Excluding Attachment A) |
• PPRRVU17_V1219 | |
• OPPSCAP_V1219 | |
Excluding: | |
17LOCCO | |
ANES_V0101 | |
CY2017_GPCIs | |
For services rendered on or after April 1, 2017: | |
RVU17B [ZIP, 3MB] | |
• RVU17B (Excluding Attachment A) | |
• PPRRVU17_V0209 | |
• OPPSCAP_V0215 | |
Excluding: | |
17LOCCO | |
ANES_V0101 | |
CY2017_GPCIs | |
For services rendered on or after July 1, 2017: | |
RVU17C [ZIP, 3MB] | |
• RVU17C (Excluding Attachment A) | |
• PPRRVU17_JULY_V0503 | |
• OPPSCAP_V0515 | |
Excluding: | |
17LOCCO | |
ANES_V0101 | |
CY2017_GPCIs | |
For services rendered on or after October 1, 2017: | |
RVU17D [ZIP, 3MB] | |
• RVUPUF17 (Excluding Attachment A) | |
• PPRRVU17_OCT | |
• OPPSCAP_OCT | |
Excluding: | |
17LOCCO | |
ANES_OCT | |
CY2017_GPCIs | |
Conversion Factors adjusted | For services rendered on or after March 1, 2017: |
for MEI and Relative | |
Value Scale adjustment | Anesthesia Conversion Factor: $26.8011 |
factor | Other Services Conversion Factor: $ 44.6572 |
Current Procedural | CPT 2017 |
Terminology (CPT®) | https://commerce.ama-assn.org/store/ |
Current Procedural | Do not use CPT codes: |
Terminology | 27215 (Use G0412) |
CPT codes that shall not | 27216 (Use G0413) |
be used | 27217 (Use G0414) |
27218 (Use G0415) | |
76140 (see § 9789.17.2) | |
90889 (See § 9789.14. Use code WC005) | |
97014 (Use G0283) | |
99075 (see Medical-Legal fee schedule, § 9795) | |
99080 (see § 9789.14) | |
99241 through 99245 (see § 9789.12.12) | |
99251 through 99255 (see § 9789.12.12) | |
99455 and 99456 | |
Diagnostic Cardiovascular | For services rendered on or after March 1, 2017: |
Procedure CPT codes | RVU17A, PPRRVU17_V1219, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in |
subject to the MPPR | CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document |
CMS-1654-F_Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after April 1, 2017: | |
RVU17B, PPRRVU17_V0209, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F_Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after July 1, 2017: | |
RVU17C, PPRRVU17_JULY_V0503, Number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F_Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after October 1, 2017: | |
RVU17D, PPRRVU17_OCT, Number “6” in column S, | |
labeled “Mult Proc” (Modifier 51), also listed in CY 2017 | |
PFS Final Rule Multiple Procedure Payment Reduction File | |
[Zip, 42KB], in the document CMS-1654-F_Diagnostic | |
Cardiovascular Services Subject to MPPR | |
Diagnostic Imaging Family | For services rendered on or after March 1, 2017: |
Indicator Description | Diagnostic Imaging Family Indicator: |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU17A, RVU17A (PDF document) | |
For services rendered on or after April 1, 2017: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU17B, RVU17B (PDF document) | |
For services rendered on or after July 1, 2017: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU17C, RVU17C (PDF document) | |
For services rendered on or after October 1, 2017: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU17D, RVUPUF17 (PDF document) | |
Diagnostic Imaging Family | For services rendered on or after March 1, 2017: |
Procedures Subject to the | RVU17A, PPRRVU17_V1219, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”, |
MPPR | also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR |
For services rendered on or after April 1, 2017: | |
RVU17B, PPRRVU17_V0209, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”, also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after July 1, 2017: | |
RVU17C, PPRRVU17_JULY_V0503, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator”, also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after October 1, 2017: | |
RVU17D, PPRRVU17_OCT, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,” also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F _Diagnostic Imaging Services Subject to MPPR | |
Diagnostic Imaging | For services rendered on or after March 1, 2017: |
Multiple Procedures | RVU17A, PPRRVU17_V1219, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2017 PFS |
Subject to the MPPR | Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F_Diagnostic Imaging Services Subject to MPPR |
For services rendered on or after April 1, 2017: | |
RVU17B, PPRRVU17_V0209, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after July 1, 2017: | |
RVU17C, PPRRVU17_JULY_V0503, number “4” in column S, labeled, “Mult Proc”, also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after October 1, 2017: | |
RVU17D, PPRRVU17_OCT, number “4” in column S, labeled, “Mult Proc,” also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the document CMS-1654-F_Diagnostic Imaging Services Subject to MPPR | |
DWC Pharmaceutical | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
Fee Schedule | |
Geographic Health | 2017 Primary Care HPSA [ZIP, 99KB] |
Professional Shortage | 2017 Mental Health HPSA [ZIP, 237KB] |
Area zip code data files | Access the files on the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index.html?redirect=/hpsapsaphysicianbonuses/ |
Health Resources and Services Administration: Geographic HPSA shortage area query | |
(By State & County) | http://hpsafind.hrsa.gov/ |
(By Address) | http://datawarehouse.hrsa.gov/geoHPSAAdvisor/GeographicHPSAAdvisor.aspx |
Incident To Codes | For services rendered on or after March 1, 2017: |
RVU17A, PPRRVU17_V1219, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator) | |
For services rendered on or after April 1, 2017: | |
RVU17B, PPRRVU17_V0209, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator) | |
For services rendered on or after July 1, 2017: | |
RVU17C, PPRRVU17_JULY_V0503, number “5” in column N, labeled, “PCTC IND”, (PC/TC Indicator) | |
For services rendered on or after October 1, 2017: | |
RVU17D, PPRRVU17_OCT, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator) | |
Medi-Cal Rates -- DHCS | Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service. |
For services rendered on or after March 1, 2017 use: | |
Medi-Cal Rates file -- Updated 2/15/2017 | |
For services rendered on or after March 15, 2017, use: | |
Medi-Cal Rates file -- Updated 3/15/2017 | |
For services rendered on or after April 15, 2017, use: | |
Medi-Cal Rates file -- Updated 4/15/2017 | |
For services rendered on or after May 15, 2017, use: | |
Medi-Cal Rates file -- Updated 5/15/2017 | |
For services rendered on or after June 15, 2017, use: | |
Medi-Cal Rates file - Updated 6/15/2017 | |
For services rendered on or after July 15, 2017, use: | |
Medi-Cal Rates file - Updated 7/15/2017 | |
For services rendered on or after August 15, 2017, use: | |
Medi-Cal Rates file - Updated 8/15/2017 | |
For services rendered on or after September 15, 2017, use: | |
Medi-Cal Rates file - Updated 9/15/2017 | |
For services rendered on or after October 15, 2017, use: | |
Medi-Cal Rates file - Updated 10/15/2017 | |
For services rendered on or after November 15, 2017, use: | |
Medi-Cal Rates file - Updated 11/15/2017 | |
For services rendered on or after December 15, 2017, use: | |
Medi-Cal Rates file - Updated 12/15/2017 | |
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm | |
Ophthalmology Procedure | For services rendered on or after March 1, 2017: |
CPT codes subject to the | RVU17A, PPRRVU17_V1219, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in |
MPPR | CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR |
For services rendered on or after April 1, 2017: | |
RVU17B, PPRRVU17_V0209, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR | |
For services rendered on or after July 1, 2017: | |
RVU17C, PPRRVU17_JULY_V0503, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR | |
For services rendered on or after October 1, 2017: | |
RVU17D, PPRRVU17_OCT, Number “7” in column S, labeled “Mult Proc” (Modifier 51). Also listed in CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB], in the CMS-1654-F_Diagnostic Ophthalmology Services Subject to MPPR | |
Physical Therapy Multiple | For services rendered on or after March 1, 2017: |
Procedure Payment | RVU17A, PPRRVU17_V1219, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2017 |
Reduction: “Always | PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB] in the document |
Therapy” Codes; and | CMS-1654-F_Separately Payable Therapy Services Subject to MPPR |
Acupuncture and | |
Chiropractic Codes | In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 |
For services rendered on or after April 1, 2017: | |
RVU17B, PPRRVU17_V0209, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB] in the document CMS-1654-F_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after July 1, 2017: | |
RVU17C, PPRRVU17_JULY_V0503, Number “5” in column S, labeled “Mult Proc”. Also listed in the CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB] in the document CMS-1654-F_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after October 1, 2017: | |
RVU17D, PPRRVU17_OCT, Number “5” in column S, labeled “Mult Proc.” Also listed in the CY 2017 PFS Final Rule Multiple Procedure Payment Reduction File [Zip, 42KB] in the document CMS-1654-F_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
Physician Time | CY 2017 PFS Final Rule Physician Time [ZIP, 628KB] |
Statewide GAFs (Other | Average Statewide Work GAF: 1.0417 |
than anesthesia) | Average Statewide Practice Expense GAF: 1.1632 |
Average Statewide Malpractice Expense GAF: 0.6632 | |
Statewide GAF | Average Statewide Anesthesia GAF: 1.0374 |
(Anesthesia) | |
Splints and Casting | For services rendered on or after March 1, 2017, use: |
Supplies | The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. |
The 1995 Documentation Guidelines for Evaluation & Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf |
The 1997 Documentation Guidelines for Evaluation and Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf |
Document/Data | Services Rendered On or After January 1, 2018 & Mid-year Updates |
---|---|
Adjustment Factors | For services rendered on or after January 1, 2018: |
(These factors have been | |
incorporated into the | For all services other than anesthesia: |
conversion factors | 2018 Cumulative adjustment factor: 1.1075 |
listed below) | 2018 RVU budget neutrality adjustment factor: 0.9990 |
2018 Annual increase in the MEI: 1.014 | |
2017 Cumulative “other than anesthesia” adjustment: 1.0933 | |
For anesthesia services: | |
2018 Cumulative anesthesia adjustment factor: 1.0604 | |
2018 RVU budget neutrality adjustment factor: 0.9990 | |
2018 Annual increase in the MEI: 1.014 | |
2018 Anesthesia practice expense and malpractice adjustment factor: 1.0034 | |
2017 Cumulative anesthesia adjustment: 1.0433 | |
Anesthesia Base Units by | cms1676f_cy_2018_anesthesia_base_units.xlsx |
CPT Code | |
California-Specific Codes | WC001 - Not reimbursable |
WC002 - $12.46 | |
WC003 - $40.45 for first page | |
$24.88 each additional page. Maximum of six pages absent mutual agreement ($164.85) | |
WC004 - $40.45 for first page | |
$24.88 each additional page. Maximum of seven pages absent mutual agreement ($189.73) | |
WC005 - $40.45 for first page, $24.88 each additional page. Maximum of six pages absent mutual agreement ($164.85) | |
WC007 - $40.45 for first page | |
$24.88 each additional page. Maximum of six pages absent mutual agreement ($164.85) | |
WC008 - $10.73 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC009 - $10.73 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC010 - $5.36 per x-ray | |
WC011 - $10.73 per scan | |
WC012 - No Fee Prescribed/Non Reimbursable absent agreement | |
CCI Edits: | For services rendered on or after January 1, 2018, use: |
Medically Unlikely Edits | “Practitioner Services MUE Table - Effective 1/1/18.” |
Copy of the MUE Table is posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
For services rendered on or after April 1, 2018, use: | |
“Practitioner Services MUE Table - Effective 4/1/18” | |
Copy of the MUE Table is posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
For services rendered on or after July 1, 2018, use: | |
“Practitioner Services MUE Table - Effective 07-01-2018 [ZIP, 346KB],” excluding all codes listed with | |
Practitioner Services MUE Value of “0” (zero). | |
Excerpts of the MUE Table is posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
For services rendered on or after October 1, 2018, use: | |
“Practitioner Services MUE Table - Effective 10-01-2018 [ZIP, 348KB],” excluding all codes listed with | |
Practitioner Services MUE Value of “0” (zero). | |
Excerpts of the MUE Table is posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
CCI Edits: | For services rendered on or after January 1, 2018: |
National Correct Coding | “NCCI Policy Manual for Medicare Services -- Effective January 1, 2018 [ZIP, 851KB]” |
Initiative Policy Manual for | |
Medicare Services | Copy of the 2018 Manual is posted on the DWC website: |
http://www.dir.ca.gov/dwc/OMFS9904.htm#7 | |
CCI Edits: | For services rendered on or after January 1, 2018: |
Practitioner Procedure to | |
Procedure (PTP) Edits | Practitioner PTP Edits v24.0 effective January 1, 2018 (511,599 records) 0001M/36591 - 25931/G0471 |
Practitioner PTP Edits v24.0 effective January 1, 2018 (507,927 records) 26010/01810 - 36909/J2001 | |
Practitioner PTP Edits v24.0 effective January 1, 2018 (474,903 records) 37140/0213T - 60650/G0471 | |
Practitioner PTP Edits v24.0 effective January 1, 2018 (514,837 records) 61000/0213T - R0075/R0070 | |
For services rendered on or after April 1, 2018: | |
Practitioner PTP Edits v24.1 effective April 1, 2018 (537,183 records) 0001M/36591 - 25931/G0471 | |
Practitioner PTP Edits v24.1 effective April 1, 2018 (482,358 records) 26010/01810 - 36909/J2001 | |
Practitioner PTP Edits v24.1 effective April 1, 2018 (523,111 records) 37140/0213T - 60650/G0471 | |
Practitioner PTP Edits v24.1 effective April 1, 2018 (466,820 records) 61000/0213T - R0075/R0070 | |
For services rendered on or after July 1, 2018: | |
Practitioner PTP Edits v24.2 effective July 1, 2018 (539,120 records) 0001M/36591 - 26992/G0471 | |
Practitioner PTP Edits v24.2 effective July 1, 2018 (482,378 records) 27000/01995 - 37790/G0471 | |
Practitioner PTP Edits v24.2 effective July 1, 2018 (523,129 records) 38100/0213T - 61888/G0471 | |
Practitioner PTP Edits v24.2 effective July 1, 2018 (467,725 records) 62000/0213T - R0075/R0070 | |
For services rendered on or after October 1, 2018: | |
Practitioner PTP Edits v24.3 effective October 1, 2018 (539,717 records) 0001M/36591 - 26992/G0471 | |
Practitioner PTP Edits v24.3 effective October 1, 2018 (482,493 records) 27000/01995 - 37790/G0471 | |
Practitioner PTP Edits v24.3 effective October 1, 2018 (523,504 records) 38100/0213T - 61888/G0471 | |
Practitioner PTP Edits v24.3 effective October 1, 2018 (467,777 records) 62000/0213T - R0075/R0070 | |
Access the Practitioner PTP Edits on the CMS website: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html | |
Note: the Practitioner PTP Edits excel file maintained by CMS contains effective date and deletion date (if any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website, and covers all time periods. | |
CMS' Medicare National | For services rendered on or after January 1, 2018: |
Physician Fee Schedule | RVU18A (Updated 12/20/2017) [ZIP, 3MB] |
Relative Value File [Zip] | • RVU18A (Excluding Attachment A) |
• PPRRVU18_JAN | |
• OPPSCAP_JAN | |
Excluding: | |
18LOCCO | |
ANES2018 | |
GPCI2018 | |
For services rendered on or after April 1, 2018: | |
RVU18B [ZIP, 3MB] | |
• RVU18B (Excluding Attachment A) | |
• PPRRVU18_APR | |
• OPPSCAP_APR | |
Excluding: | |
18LOCCO | |
ANES2018 | |
GPCI2018 | |
For services rendered on or after July 1, 2018: | |
RVU18C1 [ZIP, 3MB] | |
• RVU18C (Excluding Attachment A) | |
• PPRRVU18_JUL | |
• OPPSCAP_JUL | |
Excluding: | |
18LOCCO | |
ANES2018 | |
GPCI2018 | |
For services rendered on or after October 1, 2018: | |
RVU18D [ZIP, 3MB] | |
• RVU18D (Excluding Attachment A) | |
• PPRRVU18_OCT | |
• OPPSCAP_OCT | |
Excluding: | |
18LOCCO | |
ANES2018 | |
GPCI2018 | |
Conversion Factors adjusted | For services rendered on or after January 1, 2018: |
for MEI and Relative Value | |
Scale adjustment factor | Anesthesia Conversion Factor: $27.2415 |
Other Services Conversion Factor: $45.2371 | |
Current Procedural | CPT 2018 |
Terminology (CPT®) | https://commerce.ama-assn.org/store/ |
Current Procedural | Do not use CPT codes: |
Terminology | 27215 (Use G0412) |
CPT codes that shall not | 27216 (Use G0413) |
be used | 27217 (Use G0414) |
27218 (Use G0415) | |
76140 (see § 9789.17.2) | |
90889 (See § 9789.14. Use codeWC005 code) | |
97014 (Use G0283) | |
97127 (Use G0515) | |
99075 (see Medical-Legal fee schedule, § 9795) | |
99080 (see § 9789.14) | |
99241 through 99245 (see § 9789.12.12) | |
99251 through 99255 (see § 9789.12.12) | |
99455 and 99456 | |
Diagnostic Cardiovascular | For services rendered on or after January 1, 2018: |
Procedure CPT codes | RVU18A, PPRRVU18_JAN, number “6” in column S, |
subject to the MPPR | labeled “Mult Proc” (Modifier 51), also listed in CY 2018 |
PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after April 1, 2018: | |
RVU18B, PPRRVU18_APR, number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after July 1, 2018: | |
RVU18C1, PPRRVU18_JUL, number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR | |
For services rendered on or after October 1, 2018: | |
RVU18D, PPRRVU18_OCT, number “6” in column S, labeled “Mult Proc” (Modifier 51), also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Cardiovascular Services Subject to MPPR | |
Diagnostic Imaging Family | For services rendered on or after January 1, 2018: |
Indicator Description | Diagnostic Imaging Family Indicator: |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU18A, RVU18A (PDF document) | |
For services rendered on or after April 1, 2018: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU18B, RVU18B (PDF document) | |
For services rendered on or after July 1, 2018: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU18C1, RVU18C (PDF document) | |
For services rendered on or after October 1, 2018: | |
Diagnostic Imaging Family Indicator: | |
88 = Subject to the reduction | |
99 = Concept does not apply | |
RVU18D, RVU18D (PDF document) | |
Diagnostic Imaging Family | For services rendered on or after January 1, 2018: |
Procedures Subject to the | RVU18A, PPRRVU18_JAN, number “88” in column AB, |
MPPR | labeled, “Diagnostic Imaging Family Indicator,” also listed in CY 2018 |
PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document | |
CMS-1676-F_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after April 1, 2018: | |
RVU18B, PPRRVU18_APR, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,” also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after July 1, 2018: | |
RVU18C1, PPRRVU18_JUL, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,” also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after October 1, 2018: | |
RVU18D, PPRRVU18_OCT, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,” also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR | |
Diagnostic Imaging | For services rendered on or after January 1, 2018: |
Multiple Procedures | RVU18A, PPRRVU18_JAN, number “4” in column S, labeled, “Mult Proc,” also listed in |
Subject to the MPPR | CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR |
For services rendered on or after April 1, 2018: | |
RVU18B, PPRRVU18_APR, number “4” in column S, labeled, “Mult Proc,” also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after July 1, 2018: | |
RVU18C1, PPRRVU18_JUL, number “4” in column S, labeled, “Mult Proc,” also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR | |
For services rendered on or after October 1, 2018: | |
RVU18D, PPRRVU18_OCT, number “4” in column S, labeled, “Mult Proc,” also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Imaging Services Subject to MPPR | |
DWC Pharmaceutical | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
Fee Schedule | |
Geographic Health | 2018 Primary Care HPSA [ZIP, 98KB] |
Professional | 2018 Mental Health HPSA [ZIP, 218KB] |
Shortage Area zip code | Access the files on the CMS website: |
data files | https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index.html?redirect=/hpsapsaphysicianbonuses/ |
Health Resources and Services Administration: Geographic HPSA shortage area query | |
(By State & County) | http://hpsafind.hrsa.gov/ |
(By Address) | http://datawarehouse.hrsa.gov/geoHPSAAdvisor/GeographicHPSAAdvisor.aspx |
Incident To Codes | For services rendered on or after January 1, 2018: |
RVU18A, PPRRVU18_JAN, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator) | |
For services rendered on or after April 1, 2018: | |
RVU18B, PPRRVU18_APR, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator) | |
For services rendered on or after July 1, 2018: | |
RVU18C1, PPRRVU18_JUL, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator) | |
For services rendered on or after October 1, 2018: | |
RVU18D, PPRRVU18_OCT, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator) | |
Medi-Cal Rates -- DHCS | Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service. |
For services rendered on or after January 1, 2018, use: | |
Medi-Cal Rates file - Updated 12/15/2017 | |
For services rendered on or after January 15, 2018, use: | |
Medi-Cal Rates file - Updated 1/15/2018 | |
For services rendered on or after February 15, 2018, use: | |
Medi-Cal Rates file - Updated 2/15/2018 | |
For services rendered on or after March 15, 2018, use: | |
Medi-Cal Rates file - Updated 3/15/2018 | |
For services rendered on or after April 15, 2018, use: | |
Medi-Cal Rates file - Updated 4/15/2018 | |
For services rendered on or after May 15, 2018, use: | |
Medi-Cal Rates file - Updated 5/15/2018 | |
For services rendered on or after June 15, 2018, use: | |
Medi-Cal Rates file - Updated 6/15/2018 | |
For services rendered on or after July 15, 2018, use: | |
Medi-Cal Rates file - Updated 7/15/2018 | |
For services rendered on or after August 15, 2018, use: | |
Medi-Cal Rates file - Updated 8/15/2018 | |
For services rendered on or after September 15, 2018, use: | |
Medi-Cal Rates file - Updated 9/15/2018 | |
For services rendered on or after October 15, 2018, use: | |
Medi-Cal Rates file - Updated 10/15/2018 | |
For services rendered on or after November 15, 2018, use: | |
Medi-Cal Rates file - Updated 11/15/2018 | |
For services rendered on or after December 15, 2018, use: | |
Medi-Cal Rates file - Updated 12/15/2018 | |
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
Ophthalmology Procedure | For services rendered on or after January 1, 2018: |
CPT codes subject to | RVU18A, PPRRVU18_JAN, number “7” in column S, labeled “Mult Proc” (Modifier 51). |
the MPPR | Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR |
For services rendered on or after April 1, 2018: | |
RVU18B, PPRRVU18_APR, number “7” in column S, labeled “Mult Proc” (Modifier 51). | |
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR | |
For services rendered on or after July 1, 2018: | |
RVU18C1, PPRRVU18_JUL, number “7” in column S, labeled “Mult Proc” (Modifier 51). | |
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR | |
For services rendered on or after October 1, 2018: | |
RVU18D, PPRRVU18_OCT, number “7” in column S, labeled “Mult Proc” (Modifier 51). | |
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Diagnostic Ophthalmology Services Subject to MPPR | |
Physical Therapy Multiple | For services rendered on or after January 1, 2018: |
Procedure Payment | RVU18A, PPRRVU18_JAN, number “5” in column S, labeled “Mult Proc.” |
Reduction: “Always | Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], |
Therapy” Codes; and | in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR |
Acupuncture and | |
Chiropractic Codes | In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 |
For services rendered on or after April 1, 2018: | |
RVU18B, PPRRVU18_APR, number “5” in column S, labeled “Mult Proc.” | |
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after July 1, 2018: | |
RVU18C1, PPRRVU18_JUL, number “5” in column S, labeled “Mult Proc.” | |
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
For services rendered on or after October 1, 2018: | |
RVU18D, PPRRVU18_OCT, number “5” in column S, labeled “Mult Proc.” | |
Also listed in CY 2018 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 42KB], in the document CMS-1676-F_Separately Payable Therapy Services Subject to MPPR | |
In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
Physician Time | CY 2018 PFS Final Rule Physician Time [ZIP, 591KB] |
Statewide GAFs (Other | Average Statewide Work GAF: 1.041 |
than anesthesia) | Average Statewide Practice Expense GAF: 1.166 |
Average Statewide Malpractice Expense GAF: 0.605 | |
Statewide GAF (Anesthesia) | Average Statewide Anesthesia GAF: 1.034 |
Splints and Casting Supplies | For services rendered on or after January 1, 2018, use: |
The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) | |
Fee Schedule applicable to the date of service. | |
The 1995 Documentation Guidelines for Evaluation & Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf |
The 1997 Documentation Guidelines for Evaluation & Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf |
Document/Data | Services Rendered On or After January 1, 2019 & Mid-year Updates |
---|---|
Adjustment Factors | For all services other than anesthesia: |
(These factors have been | 2019 Cumulative adjustment factor: 1.1226 |
incorporated into the | 2019 RVU budget neutrality adjustment factor: 0.9986 |
conversion factors listed | 2019 Annual increase in the MEI: 1.015 |
below) | 2018 Cumulative “other than anesthesia” adjustment: 1.1075 |
For anesthesia services: | |
2019 Cumulative anesthesia adjustment factor: 1.0777 | |
2019 RVU budget neutrality adjustment factor: 0.9986 | |
2019 Annual increase in the MEI: 1.015 | |
2019 Anesthesia practice expense and malpractice adjustment factor: 1.0027 | |
2018 Cumulative anesthesia adjustment: 1.0604 | |
Anesthesia Base Units by | cms1676f_cy_2018_anesthesia_base_units.xlsx |
CPT Code | |
California-Specific Codes | WC001 - Not reimbursable |
WC002 - $12.65 | |
WC003 - $41.06 for first page | |
$25.25 each additional page. Maximum of six pages absent mutual agreement ($167.31) | |
WC004 - $41.06 for first page | |
$25.25 each additional page. Maximum of seven pages absent mutual agreement ($192.56) | |
WC005 - $41.06 for first page, $25.25 each additional page. Maximum of six pages absent mutual agreement ($167.31) | |
WC007 - $41.06 for first page | |
$25.25 each additional page. Maximum of six pages absent mutual agreement ($167.31) | |
WC008 - $10.89 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC009 - $10.89 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
WC010 - $5.44 per x-ray | |
WC011 - $10.89 per scan | |
WC012 - No Fee Prescribed/Non Reimbursable absent agreement | |
CCI Edits: | |
Medically Unlikely Edits | For services rendered on or after January 1, 2019, use: |
“Practitioner Services MUE Table - Effective 01/01/2019 [ZIP, 350KB],” excluding all codes listed with Practitioner Services MUE Value of “0” (zero). | |
Excerpts of the MUE Tables are posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm | |
CCI Edits: | “NCCI Policy Manual for Medicare Services - Effective January 1, 2019 [ZIP, 1MB]” |
National Correct Coding | |
Initiative Policy Manual | Copy of the 2019 Manual is posted on the DWC website: http://www.dir.ca.gov/dwc/OMFS9904.htm#7 |
for Medicare Services | |
CCI Edits: | For services rendered on or after January 1, 2019: |
Practitioner Procedure to | |
Procedure (PTP) Edits | Practitioner PTP Edits v25.0 effective January 1, 2019 (556,965 records) 0001M/36591 -- 26992/G0471 |
Practitioner PTP Edits v25.0 effective January 1, 2019 (489,643 records) 27000/01995 -- 37790/G0471 | |
Practitioner PTP Edits v25.0 effective January 1, 2019 (529,244 records) 38100/0213T -- 61888/G0471 | |
Practitioner PTP Edits v25.0 effective January 1, 2019 (483,364 records) 62000/0213T -- R0075/R0070 | |
Access the Practitioner PTP Edits on the CMS website: | |
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html | |
Note: the Practitioner PTP Edits excel file maintained by CMS contains effective date and deletion date (if any) for each column 1/column 2 pair. Therefore, the most recent file is the only file posted on the CMS website, and covers all time periods. | |
CMS' Medicare National | For services rendered on or after January 1, 2019: |
Physician Fee Schedule | RVU19A [ZIP, 3MB] |
Relative Value File [Zip] | • RVU19A-508 (Excluding Attachment A) |
• PPRRVU19_Jan | |
• OPPSCAP_Jan | |
• 19LOCCO | |
• GPCI2019 | |
Excluding: | |
ANES2019 | |
Access the Relative Value File on the CMS website: | |
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html | |
Conversion Factors | Anesthesia Conversion Factor: $27.6859 |
adjusted for MEI and | |
Relative Value Scale | Other Services Conversion Factor: $45.8513 |
adjustment factor | |
Current Procedural | CPT 2019 |
Terminology (CPT®) | https://commerce.ama-assn.org/store/ |
Current Procedural | Do not use CPT codes: |
Terminology | 27215 (Use G0412) |
CPT codes that shall | 27216 (Use G0413) |
not be used | 27217 (Use G0414) |
27218 (Use G0415) | |
76140 (see § 9789.17.2) | |
90889 (See § 9789.14. Use codeWC005 code) | |
97014 (Use G0283) | |
97127 (Use G0515) | |
99075 (see Medical-Legal fee schedule, § 9795) | |
99080 (see § 9789.14) | |
99241 through 99245 (see § 9789.12.12) | |
99251 through 99255 (see § 9789.12.12) | |
99455 and 99456 | |
Diagnostic Cardiovascular | For services rendered on or after January 1, 2019: |
Procedure CPT codes | RVU19A, PPRRVU19_Jan, number “6” in column S, labeled “Mult Proc” (Modifier 51), |
subject to the MPPR | also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-F_Diagnostic Cardiovascular Services Subject to MPPR |
Diagnostic Imaging | For services rendered on or after January 1, 2019: |
Family Indicator | Diagnostic Imaging Family Indicator: |
Description | 88 = Subject to the reduction |
99 = Concept does not apply | |
RVU19A, RVU19A-508 (PDF document) | |
Diagnostic Imaging | For services rendered on or after January 1, 2019: |
Family Procedures | RVU19A, PPRRVU19_Jan, number “88” in column AB, labeled, “Diagnostic Imaging Family Indicator,” |
Subject to the MPPR | also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-F_Diagnostic Imaging Services Subject to MPPR |
Diagnostic Imaging | For services rendered on or after January 1, 2019: |
Multiple Procedures | RVU19A, PPRRVU19_Jan, number “4” in column S, labeled “Mult Proc,” |
Subject to the MPPR | also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-F_Diagnostic Imaging Services Subject to MPPR |
DWC Pharmaceutical | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
Fee Schedule | |
Geographic Practice Cost | For services rendered on or after January 1, 2019: |
Index (GPCI) by locality | RVU19A |
(Other than anesthesia | • GPCI2019 Addendum E - Column B (“Locality Number”), column C (“Locality Name”), |
services) | column D (“2019 PW GPCI”), column E (“PE GPCI”), and column F (“MP GPCI”) for the State of California (“CA”) |
• 19LOCCO - Column B (“Locality Number”), column C (“State”), column D (“Fee Schedule Area”), and column E (“Counties”) for the State of California (“CA”) | |
Access the Relative Value File on the CMS website: | |
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html | |
Also, see Zip Code mapping files listed below. | |
Geographic Practice Cost | For services rendered on or after January 1, 2019: |
Index (GPCIs) by locality | |
and anesthesia shares | 2019 Anesthesia Conversion Factors [ZIP, 18KB] (These factors have been incorporated into the conversion |
(Anesthesia) | factors listed on section 9789.19.1, Table A) |
• Locality-Adjusted Anesthesia Conversion Factors as a result of the CY 2019 Final Rule, excluding column G labeled, “National Anes CF of 22.2730” | |
• Anesthesia Shares | |
RVU19A (County to locality index) | |
• 19LOCCO - Column B (“Locality Number”), column C (“State”), column D (“Fee Schedule Area”), and column E (“Counties”) for the State of California (“CA”) | |
Access the Anesthesia Conversion Factors File on the CMS website: | |
https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html | |
Access the Relative Value File on the CMS website: | |
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html | |
Also, see Zip Code mapping files listed below. | |
Geographic Practice Cost | For services rendered on or after January 1, 2019: |
Index (GPCI) locality | |
mapping | Zip Code to Carrier Locality File - Revised 11/14/2018 [ZIP, 4MB], Column A (“STATE”), column B (“ZIP CODE”), and column D (“LOCALITY”) for the State of California (“CA”) |
Zip Code files mapping | Zip Codes requiring + 4 extension - Revised 11/14/2018 [ZIP, 1KB], for the State of California (“CA”) |
zip codes to GPCI | |
locality (for “other than | The Zip Code files can be accessed on the CMS website: |
anesthesia services” and | https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html |
anesthesia services) | |
Geographic Health | 2019 Primary Care HPSA [ZIP, 100KB] |
Professional Shortage | 2019 Mental Health HPSA [ZIP, 218KB] |
Area zip code data files | |
Access the files on the CMS website: | |
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index.html?redirect=/hpsapsaphysicianbonuses/ | |
Health Resources and Services Administration: Geographic HPSA shortage area query | |
(By State & County) | http://hpsafind.hrsa.gov/ |
(By Address) | http://datawarehouse.hrsa.gov/geoHPSAAdvisor/GeographicHPSAAdvisor.aspx |
Incident To Codes | For services rendered on or after January 1, 2019: |
RVU19A, PPRRVU19_Jan, number “5” in column N, labeled, “PCTC IND,” (PC/TC Indicator) | |
Medi-Cal Rates - DHCS | Pursuant to section 9789.13.2, the Medi-Cal Rates file's “Basic Rate” is used in calculating maximum fee for physician-administered drugs, biologicals, vaccines or blood products, by date of service. |
For services rendered on or after January 1, 2019, use: | |
Medi-Cal Rates file - Updated 12/15/2018 | |
Copies of the Medi-Cal Rates files (without CPT descriptors) are posted on the DWC website: | |
http://www.dir.ca.gov/dwc/OMFS9904.htm | |
Ophthalmology Procedure | For services rendered on or after January 1, 2019: |
CPT codes subject to | RVU19A, PPRRVU19_Jan, number “7” in column S, labeled “Mult Proc” (Modifier 51). |
the MPPR | Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-F_Diagnostic Ophthalmology Services Subject to MPPR |
Physical Therapy Multiple | For services rendered on or after January 1, 2019: |
Procedure Payment | RVU19A, PPRRVU19_Jan, number “5” in column S, labeled “Mult Proc.” |
Reduction: “Always | Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], |
Therapy” Codes; and | in the document CMS-1693-F_Separately Payable Therapy Services Subject to MPPR |
Acupuncture and | |
Chiropractic Codes | In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 |
Physician Time | CY 2019 PFS Final Rule Physician Time [ZIP, 244KB] |
Splints and Casting Supplies | The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. |
The 1995 Documentation Guidelines for Evaluation & Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf |
The 1997 Documentation Guidelines for Evaluation & Management Services | https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf |
Credits
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
History
1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).
2. Amendment of table filed 12-26-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 52).
3. Editorial correction of Table (Register 2015, No. 16).
4. Amendment of subsection (a) and new subsections (b) and (c) filed 3-23-2016; operative 1-1-2016 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2016, No. 13).
5. Editorial correction (Register 2017, No. 5).
6. Amendment of subsection (c) and new subsection (d) filed 7-18-2017; operative 3-1-2017. Submitted to OAL as a file and print only pursuant to Labor Code section 5307.1(g)(2) (Register 2017, No. 29).
7. Editorial correction of subsection (c) table headings (Register 2017, No. 30).
8. Amendment of subsection (d) and new subsection (e) filed 12-28-2017; operative 1-1-2018. Submitted to OAL for filing and printing only pursuant to Labor Code section 5307-1(g)(2) (Register 2017, No. 52).
9. Amendment filed 11-6-2018; operative 1-1-2019. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2018, No. 45).
10. Editorial correction of subsection (e) (Register 2018, No. 52).
11. Amendment of subsections (e) and (f) filed 12-26-2018; operative 1-1-2019. Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2018, No. 52).
12. Editorial correction of subsection (f) (Register 2019, No. 22).
This database is current through 4/26/24 Register 2024, No. 17.
Cal. Admin. Code tit. 8, § 9789.19, 8 CA ADC § 9789.19
End of Document |