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California Medical Bill Reviewer Certification. Unit 2: Official Medical Fee Schedule Module 2: Physician Services General Guidelines. Overview. The Official Medical Fee Schedule, or OMFS, includes reimbursement guidelines for the different physician services.

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California Medical Bill Reviewer Certification

Unit 2: Official Medical

Fee Schedule

Module 2: Physician Services General Guidelines


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Overview

The Official Medical Fee Schedule, or OMFS, includes reimbursement guidelines for the different physician services.

Then, you will learn about the different reports that physician’s can use and how to calculate reimbursements correctly.

In this module, you will learn how the OMFS is organized, who can use the OMFS, and the general information and guidelines that apply to the OMFS.

Let’s start by discussing how the OFMS is broken down, and who can use the OMFS to bill for services, treatments, and supplies...

Part I: General Information

  • Official Medical Fee Schedule: How it is Organized

  • Service Providers: Who Can Use the Fee Schedule?

  • General Information and Instructions

    • Separate Procedures

    • Procedures Without Unit Value

    • Supplies, Materials, and Supplements

    • Special Services

    • Prolonged Service Codes

Part I: General Information

  • Official Medical Fee Schedule: How it is Organized

  • Service Providers: Who Can Use the Fee Schedule?


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The OMFS includes General Information and Instructions, as well as six major sections.

Official Medical Fee Schedule: Physician Services

Medicine includes:

  • Physical Medicine

  • Manipulative Treatment

  • Special Services

OFMS Sections:

  • Evaluation and Management

  • Anesthesiology

  • Surgery

  • Radiology

  • Pathology and Laboratory

  • Medicine


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“Any provider, regardless of specialty, may use any section of the OMFS containing procedures performed within his or her scope of practice or license…” EXCEPT:

Service Providers

Evaluation & Management: Only physicians, physician assistants, and nurse practitioners may use E & M codes.

Assessment & Evaluation:

Only physical therapists may use A & E codes.

Osteopathic Manipulation: Only licensed DOs and MDs may use osteopathic manipulation codes.

Consultation: Only physicians may use consultation codes.


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Service Providers: Physicians

Psychologists*

Chiropractors*

Podiatrists*

Medical Doctors

Dentists*

Optometrists*

Acupuncturists*

  • *Acting within scope of their practice.


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Service Providers: Non-Physicians

Licensed Clinical Social Workers

Nurse Practitioners

Orthotists &

Prosthetists

Marriage/Family Counselors

Physician’s Assistants

Physical Therapists

  • Acting within scope of license, certification, or education.

  • Require authorization from payor to treat the injured worker.


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General Information and Instructions

Now that you are familiar with the types of providers that can use the OMFS, let’s take a look at some general guidelines & instructions...

  • Part I: General Information

  • Official Medical Fee Schedule: How it is Organized

  • Service Providers: Who Can Use the Fee Schedule?

  • General Information and Instructions

    • Separate Procedures

    • Procedures Without Unit Value

    • Supplies, Materials, and Supplements

    • Special Services

    • Prolonged Service Codes

  • General Information and Instructions

    • Separate Procedures

    • Procedures Without Unit Value

    • Supplies, Materials, and Supplements

    • Special Services

    • Prolonged Service Codes


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General Information and Instructions

  • The General Information and Instructions section provides guidelines on a wide range of topics.

Topics include:

  • Separate Procedures

  • Procedures without Unit Value

  • Supplies & Materials

  • Dietary Supplements

  • Special Services

  • Prolonged Service Codes

  • Reports


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Some listed procedures are carried out as an integral part of a total service, while other procedures are independent of additional services.

Procedures that are integral parts of a total service DO NOT warrant separate identification or reimbursement.

Separate Procedures

  • Separate Procedure: a procedure independent of, and not immediately related to, other services performed, for which reimbursement is ALLOWED.

Let’s take a look…


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For Example:

Separate Procedures

CPT 95851, which codes for a Range of Motion procedure, is an essential part of a follow up visit for a shoulder injury. Therefore, it WOULD NOT warrant separate reimbursement.

However, if this procedure were the only service performed, it would be considered a separate procedure and should be ALLOWED.


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Most procedures listed in the OMFS have a relative value (RV). However, relative values are not listed for all procedures in the OMFS.

Unlisted procedures are typically uncommon or variable services, and are coded as By Report (BR) procedures.

Procedures Without Unit Value

  • Those procedures without a relative value are known as procedures without unit value.

  • Fees for procedures without a unit value must be justified by report.


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Some chiropractors bill large amounts for the use of this table, when in fact, it is just another form of manual traction.

Unlisted procedures in physical medicine are often used to bill for variations on manual traction or manipulation using a different table or technique.

Procedures Without Unit Value:An Example

Sometimes $500-$1000 is charged for a specific chiropractic table known as VAX-D.

Instead of an unlisted code, the CPT 97122, should be used.


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Every effort should be made to identify the service performed for those procedure codes that have no listed value.

As you know, providers often misuse the unlisted code when a more appropriate code is available.

Procedures Without Unit Value

Hmm, which code should I use?


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What should you do?

Procedures Without Unit Value

If you cannot identify an appropriate code, it is permissible to recommend the allowance of a like code equal in scope, time, and complexity of the service being performed.


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You may want to ask for help from your supervisor, or other colleagues familiar with medical reimbursements before paying in full.

Procedures Without Unit Value

If the necessity of the services has been verified, and the service authorized, additional documentation may be requested about the procedure, or an online search may be performed.

Payment in full is a last resort, after all other avenues have been explored.


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Supplies and/or materials normally necessary to perform a service are not separately reimbursable.

Only those supplies and materials provided above and beyond items usually included with the service may be separately reimbursed.

Supplies & Materials

These include supplies such as:

  • Cotton balls

  • Band-Aids

  • Applied meds/ointments


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Supplies and Materials

  • Reimbursement for most supplies and materials is paid at cost plus a 20% markup with a maximum of $15.00.

Supplies not reimbursed at this rate include:

  • Dispensed DME

  • Supplies not covered under the DMEPOS


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Supplies and Materials

  • Dispensed DME reimbursement is paid at the purchase price, (including tax, shipping & handling) plus 50% with a maximum markup of $25.00.


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Dietary Supplements

  • Dietary supplements such as minerals and vitamins are not reimbursable unless a dietary deficiency has been clinically established as a result of the industrial injury or illness.


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Special Services

  • Special Services areservices provided adjunct to the basic services rendered.

Special Service Characteristics:

  • Billed with CPT 99025 – 99199.

  • Special services should only be billed when circumstances clearly warrant an additional charge beyond the scheduled charges for the standard service.


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Special Service Codes

CPT 99025: Initial visit when billed with a starred procedure.

  • Only associated with surgical procedures.

CPT 99048: Lengthy or repeated telephone calls by providers to employers or other appropriate agencies regarding an injured worker’s return to work.

  • This should NOT be allowed as this is included with E&M services.


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Special Service Codes

CPT 99049: Missed Appointment.

  • Does not imply that compensation is owed.

  • Reimbursement is at the insurer’s discretion.

CPT 99050: Services provided after hours.

CPT 99058: Services provided on an emergency basis.


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Special Service Codes

CTP 99065: Outside regular hours.

  • Technical component

CPT 99071: Educational supplies such as tapes, pamphlets, books.

CPT 99086: Reproduction of chart notes.

CPT 99087: Duplicate reports.


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Prolonged Service Code Characteristics:

Prolonged Service Codes

  • Prolonged Service Codes are codes used when a physician provides a service beyond the typical service time for a specific E & M code.

  • The service provided and the length of time required must be identified and documented.

  • An associated report may be charged for CPT 99080.


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Prolonged Service Codes

  • There are two types of prolonged service codes:

Direct (Face to Face) Contact

Without Direct Contact

Let’s take a look…


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Direct (Face to Face) Contact

Direct (Face to Face) Contact

Outpatient setting:

Inpatient setting:

  • CPT 99354: 31 to 60 minutes.

  • CPT 99355: Each additional 30 minute increment.

  • CPT 99356: 31 to 60 minutes.

  • CPT 99357: Each additional 30 minute increment.


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Without Direct Contact

Without Direct Contact

CPT 99358: used when a physician spends 15 minutes or more reviewing records and tests, or communicating with other medical professionals, during or following direct contact with a patient.


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All About Reports

Now that you are familiar with some of the services that service providers bill for, you are ready to learn how providers report everything…

Let’s start by comparing reimbursable and non-reimbursable reports...

Part II: All About Reports

  • Reimbursable Reports

  • Non-Reimbursable Reports

  • Special Reports

Part II: All About Reports

  • Reimbursable Reports

  • Non-Reimbursable Reports


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Reports

  • There are two general categories of medical reports.

Separately Reimbursable

Treatment Reports

Reports that are payable in addition to the associated E & M service for an office visit.

Treatment Reports

Not Separately Reimbursable

Reports for which the charge is included in the fee for the associated E & M service for an office visit.


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Treatment Reports

Not Separately Reimbursable

Treatment Reports not Separately Reimbursable

Initial Treatment Report and Plan:

a report which details the initial treatment of the patient’s injury or illness.

Report by Secondary Physician to the Primary Treating Physician (PTP):

a report of a patient’s status and treatment provided to the PTP.

Initial Treatment Report and Plan

Report by Secondary Physician to the Primary Treating Physician (PTP)

Doctor’s First Report of Injury

Doctor’s First Report of Injury: a report provided by the patient’s primary care provider or initial treating physician.


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Treatment Reports

Not Separately Reimbursable

Treatment Reports not Separately Reimbursable

Treating Physician’s Report of Disability Status

(DWC Form RU-90):

a report which is used when the physician is unable to provide an opinion regarding the injured employee’s ability to return to his/her occupation.

Diagnostic/Testing Report: a report used to communicate diagnostic and test results.

Diagnostic/Testing Report

Treating Physician’s Report of Disability Status

(DWC Form RU-90)


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Separately Reimbursable

Treatment Reports

Separately Reimbursable Reports

Primary Treating Physicians’ Progress Report

(DWC form PR-2)

Primary Treating Physicians’ Progress Report

(DWC form PR-2):

a report used when there is a significant change in the patient’s condition or treatment plan.

Final Treating Physician’s Report of Disability Status (DWC Form RU-90):

a reported used when the physician makes a decision regarding an injured employee’s ability to return to work.

Final Treating Physician’s Report of Disability Status (DWC Form RU-90)


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Separately Reimbursable

Treatment Reports

Separately Reimbursable Reports

Primary Treating Physician's Final Discharge Report

Primary Treating Physician's Final Discharge Report:

a report used when the PTP determines that no additional treatment is required, the patient is without permanent disability, and can return to work in his or her original capacity.


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Separately Reimbursable

Treatment Reports

Separately Reimbursable Reports

Primary Treating Physician's Permanent & Stationary Report

Primary Treating Physician's Permanent & Stationary Report:

a report used when the physician determines that the patient’s condition is permanent and stationary. Physician will report the extent of permanent damage, limitations, and the need for ongoing medical care.


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Separately Reimbursable

Treatment Reports

Separately Reimbursable Reports

Consultation Report

Consultation Report:

a report used by a consulting physician from whom a consultation regarding one or more medical issues was requested by a treating physician, a third party, the Administrative Director, or the Workers’ Compensation Appeals Board.


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Special Reports

Treatment Reports

Not Separately Reimbursable

Special Reports

  • In addition to reimbursable and non-reimbursable reports, there are special reports.

Separately Reimbursable

Treatment Reports


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Special Reports

Special Reports

  • Special Reports (CPT 99080) are reports completed in addition to the standard procedure.

Special reports may include:

  • Requested reports with Modifier –18.

  • Reports billed with prolonged service codes.


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Special reports are reimbursed using the Medicine Conversion Factor (CF) multiplied by the Relative Value (RV).

Special Reports

Special Reports Reimbursement

Special Reports Relative Value:

  • RV: 6.5 for the first page and 4.0 for each additional page, less 5%.

  • Reimbursement is limited to a total of six pages.


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How Do I Calculate the Reimbursement?

  • So, what would the total reimbursement be for an eight page report?

CF and RV can be found on OMFS

Table A!

Special Reports (99080) are listed under the Medicine section.

Recall that the Medicine conversion factor is $6.15.

RV x CF x 0.95 = TOTAL REIMBURSEMENT

RV =

6.0(1 page)

+ 4.0(5 pages)

= 26.0

CF = $6.15

26.0 x $6.15 x 0.95 =$151.91


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OMFS Section Guidelines

Each section of the OMFS has general guidelines that provide information about specific ground rules and modifiers that apply to that section.

Let’s take a look…


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Ground Rules

  • Ground Rules are general guidelines at the beginning of each section of the OMFS which pertain to that section.

Ground Rules include topics such as:

  • Classification of services within the section.

  • Definitions of commonly used terms within the section.

  • Unlisted and separately identifiable procedures.

  • Billing procedures and time reporting.

  • It is important to read and follow the Ground Rules

    so that correct reimbursements are issued.


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Modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition.

Modifiers

  • A list of modifiers specific to each section in the OMFS follow the Ground Rules that pertain to that section.

Modifiers may indicate circumstances such as:

For a complete list of modifiers, see the OMFS.

  • Only part of the whole procedure was performed.

  • A bilateral procedure was performed.


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Pricing Conversion Factors

  • Pricing Conversion Factor: a numerical factor used to convert relative value units to dollar amounts for reimbursement.

  • Each section of the OMFS applies specific pricing conversion factors.


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Together, conversion factors and relative value units are used to calculate the appropriate reimbursement for any procedure, treatment, or supply.

Relative Value Units (RVU)

  • As you know, services and procedures can vary greatly in scope and complexity. Therefore, each code is given a Relative Value Unit (RVU) that is used in determining reimbursement.

RV x CF x 0.95 =

TOTAL REIMBURSEMENT


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Looking up Reimbursements

  • Just like reimbursements for special reports, specific procedure reimbursements can be found in OMFS Table A.

For services on or after May 14, 2005, please refer to the following link: http://www.dir.ca.gov/dwc/dwcpropregs/OMFS_Regulations/OMFS_tableAMay.pdf

Be sure to check the DIR website often for updates: http://www.dir.ca.gov/dwc/OMFS9904.htm

Let’s take a look…


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OMFS Table A

Conversion Factor

Relative Value

Reduction Percent

Procedure Code

OMFS Maximum


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Calculating Reimbursements

Although the bill review system calculates reimbursements, it is important that you understand how reimbursement calculation works.

Let’s take a look…


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Calculating Reimbursements

  • Reimbursement rates in the OMFS cannot fall below the Medicare rates.

Why do we multiply the total value by 0.95?

To calculate reimbursements, multiply the Relative Value (RV) by the Conversion Factor (CF) of each procedure, less 5%.

100 – 5 = 95

So, to reduce the total reimbursement by 5%, you need to multiply the total by 95%.

RV x CF x 0.95 = TOTAL REIMBURSEMENT


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Calculating Reimbursements

  • Suppose you need to calculate a reimbursement rate for CPT 99192.

What is the relative value?

What is the conversion factor?

44.8

6.15


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Calculating Reimbursements

What is the relative value?

What is the conversion factor?

44.8

6.15

RV x CF x 0.95 = 44.8 X 6.15 X 0.95 = $261.74


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Calculating Reimbursements

  • Now, suppose you need to calculate the reimbursement for CPT 99203.

What is the relative value?

What is the conversion factor?

9

8.5


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Why is the calculated reimbursement lower than the OMFS maximum?

Calculating Reimbursements

What is the relative value?

What is the conversion factor?

9

8.5

RV x CF x 0.95 = 9 X 8.5 X 0.95 = $72.68


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Did you remember that reimbursement rates cannot fall below the Medicare rate?

Calculating Reimbursements

Notice that the reduction percentage is 0%, not 5%.

Because the reimbursement amount would have fallen below the Medicare rate with a 5% reduction, the reimbursement was reduced by a smaller amount. In this case, it wasn’t reduced at all!


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Calculating Reimbursements

  • It is important to know that the bill review system calculates and applies these reimbursements for you.

But, as you can see, knowing how to calculate reimbursements may help you identify errors during bill review or troubleshoot problems when reviewing challenging bills.


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OMFS: Content, organization, & who can use it.

What constitutes special services.

Going Above and Beyond: Prolonged Service Codes

Differentiated between separate procedures and procedures without value.

Differentiated between reimbursable, non-reimbursable, and special reports.

How to calculate reimbursements.

Summary


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Module 2 Quiz

Click on the link to go directly to the quiz. Feel free to review any of the material before you move on.

Good Luck!

Quiz:

U2M2: Physician's Services


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