Workers CompensationWorkers CompensationMedical Fee Schedule Medical Fee Schedule

OverviewOverview

Paul SmallcombPaul SmallcombClient Service Manager Client Service Manager

Medical Group Business ServicesMedical Group Business Services

Physician’s Fee SchedulePhysician’s Fee Schedule

1999 Official Medical Fee Schedule 1999 Official Medical Fee Schedule BookBook

All Physician’s ServicesAll Physician’s Services Evaluation and ManagementEvaluation and Management AnesthesiaAnesthesia SurgerySurgery Radiology- all service locationsRadiology- all service locations MedicineMedicine Physical MedicinePhysical Medicine Special ServicesSpecial Services

Current Physician Fee Current Physician Fee ScheduleSchedule

Evaluation and Management Evaluation and Management (E&M) codes increased in 2007 by (E&M) codes increased in 2007 by 23%23%

Last increase in most other codes Last increase in most other codes was in 1984 and then most was in 1984 and then most decreased in 2004 by 5%decreased in 2004 by 5%

Use 1997 and 1994 CPT codesUse 1997 and 1994 CPT codes Charge basedCharge based

Revising the Physician’s Revising the Physician’s FeeFeeScheduleSchedule

UCLA study 1999: concluded Resource-UCLA study 1999: concluded Resource-Based Relative Value System (RBRVS) Based Relative Value System (RBRVS) best alternative and will increase best alternative and will increase fairnessfairness

In place for Federal Gov. for 16+ yearsIn place for Federal Gov. for 16+ years Maintained by Centers for Medicare Maintained by Centers for Medicare

and Medicaid Services (CMS)and Medicaid Services (CMS) Does not mean we’re going to Does not mean we’re going to

“Medicare” fee schedule“Medicare” fee schedule

Ground RulesGround Rules

Will review all Will review all ExamplesExamples

– – Physical therapyPhysical therapy– Second surgerySecond surgery– Correct Coding Initiative (CCI) editsCorrect Coding Initiative (CCI) edits

Components of RBRVSComponents of RBRVS

Physician work – 52%Physician work – 52% Practice Expense – 42%Practice Expense – 42% Professional Liability Insurance Professional Liability Insurance

(PLI)– 4%(PLI)– 4%

Physician WorkPhysician Work

Time required to perform the Time required to perform the serviceservice

Technical skill and physical effortTechnical skill and physical effort Mental effort and judgmentMental effort and judgment Psychological stress about Psychological stress about

iatrogenic risk to the patientiatrogenic risk to the patient

Practice ExpensePractice Expense

Direct cost – actual equipment Direct cost – actual equipment utilization ratesutilization rates

Indirect cost - staff, equipment, Indirect cost - staff, equipment, supplies and expenses not just supplies and expenses not just tied to the specific proceduretied to the specific procedure

Lewin GroupLewin Group

Using CWCI dataUsing CWCI data Model ground rules under OMFS Model ground rules under OMFS

and RVBRSand RVBRS Crosswalk old CPT codes to new Crosswalk old CPT codes to new

onesones Analyze dataAnalyze data

– Calculate payment-neutral conversion Calculate payment-neutral conversion factor which does not mean that is factor which does not mean that is what we will ultimately adoptwhat we will ultimately adopt

DecisionsDecisions

Multiple modelsMultiple models Ground rulesGround rules Conversion factorsConversion factors

– – Multiple or singleMultiple or single

– – Payment level (s)Payment level (s) Geographic adjustment factorsGeographic adjustment factors

Most Recent Changes toMost Recent Changes toPhysician Fee SchedulePhysician Fee Schedule

For physician services rendered on or after For physician services rendered on or after February 15, 2007, the maximum allowable February 15, 2007, the maximum allowable reimbursement amounts for procedure codes reimbursement amounts for procedure codes 99201 through 99205 and 99211 through 99215 99201 through 99205 and 99211 through 99215 are set forth in the February, 2007 Addendum To are set forth in the February, 2007 Addendum To Table A, “OMFS Physician Services Fees for Table A, “OMFS Physician Services Fees for Services Rendered on or after February 15, 2007.” Services Rendered on or after February 15, 2007.”

The February, 2007 Addendum to Table A, “OMFS The February, 2007 Addendum to Table A, “OMFS Physician Services Fees for Services Rendered on Physician Services Fees for Services Rendered on or after February 15, 2007”, sets forth individual or after February 15, 2007”, sets forth individual procedure codes with the corresponding procedure codes with the corresponding maximum reimbursable fees, is incorporated by maximum reimbursable fees, is incorporated by reference.reference.

Changes to E/M CodesChanges to E/M Codes

OMFS SectionOMFS SectionProcedure Procedure

CodeCode 5-14-05 OMFS 5-14-05 OMFS

Maximum Maximum 2-15-07 OMFS Maximum 2-15-07 OMFS Maximum IncreaseIncrease1-01-07 Medicare 1-01-07 Medicare

MaximumMaximum

E&ME&M 9920199201 $39.10$39.10 $39.90$39.90 2.1%2.1% $25.58$25.58

E&ME&M 9920299202 $57.80$57.80 $70.19$70.19 21.4%21.4% $51.11$51.11

E&ME&M 9920399203 $76.50$76.50 $103.86$103.86 35.8%35.8% $78.33$78.33

E&ME&M 9920499204 $109.65$109.65 $146.12$146.12 33.3%33.3% $127.66$127.66

E&ME&M 9920599205 $145.35$145.35 $186.73$186.73 28.5%28.5% $167.76$167.76

E&ME&M 9921199211 $23.80$23.80 $23.81$23.81 0.4%0.4% $9.78$9.78

E&ME&M 9921299212 $35.70$35.70 $42.02$42.02 17.7%17.7% $26.17$26.17

E&ME&M 9921399213 $47.60$47.60 $56.93$56.93 19.6%19.6% $48.72$48.72

E&ME&M 9921499214 $72.25$72.25 $89.57$89.57 24.0%24.0% $77.24$77.24

E&ME&M 9921599215 $110.50$110.50 $129.41$129.41 17.1%17.1% $111.75$111.75

Medicare Based Fee Medicare Based Fee Schedules 120% of Schedules 120% of Medicare RatesMedicare Rates

Clinical Laboratory – updated annuallyClinical Laboratory – updated annually DME – updated quarterlyDME – updated quarterly

– All suppliers: wholesale, retail, mail-order, providerAll suppliers: wholesale, retail, mail-order, provider Orthotics, Prosthetics and Supplies – updated Orthotics, Prosthetics and Supplies – updated

quarterlyquarterly Inpatient Facility – updated annuallyInpatient Facility – updated annually Outpatient Facility – OPPS Schedule – Outpatient Facility – OPPS Schedule –

updated annuallyupdated annually– – Hospital Outpatient DepartmentsHospital Outpatient Departments– – Ambulatory Surgery CentersAmbulatory Surgery Centers

Ambulance – updated annuallyAmbulance – updated annually

Pharmacy ServicesPharmacy Services

Medi-Cal Based Fee ScheduleMedi-Cal Based Fee Schedule– 100% of Medi-Cal’s rates100% of Medi-Cal’s rates– Applies to anyone dispensing Applies to anyone dispensing

pharmaceuticalspharmaceuticals– Web based calculatorWeb based calculator– Database updated first day of each Database updated first day of each

week.week.– Doesn’t include repackaged drugsDoesn’t include repackaged drugs

Medi-Cal’s Basic Medi-Cal’s Basic FormulaFormula

The basic formula for reimbursement The basic formula for reimbursement is 83% of AWP + $7.25 dispensing fee.is 83% of AWP + $7.25 dispensing fee.

Skilled Nursing Facilities are entitled to Skilled Nursing Facilities are entitled to a $8.00 dispensing fee.a $8.00 dispensing fee.

Over-the-counter medication is paid Over-the-counter medication is paid per the formula with no dispensing fee.per the formula with no dispensing fee.

Medical providers should provide the Medical providers should provide the NDC number of the dispensed NDC number of the dispensed pharmaceuticalpharmaceutical

Where Are They Found?Where Are They Found?

1999 Official Medical Fee Schedule1999 Official Medical Fee Schedule DWC’s web site DWC’s web site

www.dir.ca.gov/dwcwww.dir.ca.gov/dwc Medicare’s web site Medicare’s web site

www.cms.hhs.govwww.cms.hhs.gov Medi-Cal’s web site www.medi-Medi-Cal’s web site www.medi-

cal.ca.govcal.ca.gov

Thank YouThank You

Questions?Questions?