CA Fee Schedule Updates

As many people know, fee schedules are constantly changing. Trying to stay on top of all of them can be a challenge. IMS will be providing updates to help industry insiders understand what changes may affect you and your organization.

In California, the DWC adopted some significant changes to the Official Medical Fee Schedule that are effective for dates of service on or after 03/01/17.  These changes will have an impact on medical expense in 2017.  There are over 17,000 reimbursement changes, but the following are the most significant changes that we believe are important to share with you.

Prolonged Services –  One of the most significant changes is that the fee schedule brought back procedure code 99358, Prolonged Evaluation and Management Services Before and After Patient Care, 1st Hour which pays $149.50 and procedure code 99359,  Prolonged Evaluation and Management Services Before and After Patient Care, Ea. Additional 30 Minutes, which pays $71.97. These codes, along with consultations, were previously dropped from the fee schedule a few years ago, and in our opinion, really saved employers a lot of money as they were widely abused.  Providers are excited about this change because it presents a new lucrative revenue stream. The prolonged service codes are most often used for the reimbursement of review of records.  Our Technical Analysts have years of experience in this area as they were previously incorporated in the older fee schedules. They closely scrutinize the use of these codes and require providers to submit supporting documentation to support the reimbursement.

Telehealth – The fee schedule is now addressing a reimbursement formula for telehealth which is where health services and health-related services are provided or received, through a telecommunication system.

Conversion Factors – The conversion factors are a data element that impacts the calculation of each procedure.  The conversion factors have changed for dates of service on or after 03/01/17.  As a result, anesthesia dropped by 6.94%, surgery dropped by 7.35%, radiology dropped by 5.91%, but “All Other Services” (some examples include office, hospital, and chiro visits, medicine procedures, and physical therapy) have gone up by 5.18%.

Radiology – Although the conversion factor dropped for radiology, the professional component (reading of the x-ray) has increased for the billing of multiple procedures.  Subsequent professional component (PC) services that were provided to the same patient, in the same session, on the same day, previously paid at 75% of the procedure’s PC value. Now they pay at 95% of the procedure’s PC value.  Payment of x-ray imaging services, when using film, previously paid at the total value of the technical component (taking of the x-ray). Now they only pay at 80% of the value, and subsequent procedures are reduced accordingly.

Please make sure you visit California’s DWC website for more details. Also feel free to contact IMS to help reduce your medical costs.