Cal. Code Regs. tit. 8 § 9789.18.1

Current through Register 2024 Notice Reg. No. 44, November 1, 2024

Section 9789.18.1 - Payment for Anesthesia Services - General Payment Rule

(a) For dates of service on or after January 1, 2014, but before January 1, 2019:

The fee schedule amount for physician anesthesia services is, with the exceptions noted, based on allowable base and time units multiplied by an anesthesia conversion factor and statewide anesthesia GAF.

The maximum reasonable fee for physician and non-physician practitioner anesthesia services shall be calculated as follows:

[Base Unit + Time Unit] * CF * Statewide Anesthesia GAF = Base Maximum Fee

The base maximum fee for the procedure code is the maximum reasonable fee, except as otherwise provided by applicable provisions of this fee schedule, including but not limited to the application of ground rules and modifiers that affect reimbursement.

(1) Base Unit: The base unit for each anesthesia procedure is listed in a file entitled "Anesthesia Base Units by CPT Code," which is adopted and incorporated by reference. See Section 9789.19 for reference to the "Anesthesia Base Units by CPT Code" file, by date of service.

(2) Time Units: The way in which time units are to be calculated is set forth in Section 9789.18.8.

(3) Anesthesia Conversion Factor and Statewide Anesthesia GAF: See Section 9789.19 for the anesthesia conversion factor and statewide anesthesia GAF, by date of service.

(b) For dates of service on or after January 1, 2019:

The fee schedule amount for physician anesthesia services is, with the exceptions noted, based on allowable base and time units multiplied by an anesthesia conversion factor adjusted by the anesthesia shares and Geographic Practice Cost Index (GPCIs) specific to a locality where the service was provided.

The maximum reasonable fee for physician and non-physician practitioner anesthesia services shall be calculated as follows:

[Base Unit + Time Unit] * Adjusted CF by locality = Base Maximum Fee

The base maximum fee for the procedure code is the maximum reasonable fee, except as otherwise provided by applicable provisions of this fee schedule, including but not limited to the application of ground rules and modifiers that affect reimbursement.

(1) Base Unit: The base unit for each anesthesia procedure is listed in a file entitled "Anesthesia Base Units by CPT Code", which is adopted and incorporated by reference. See Section 9789.19 for reference to the "Anesthesia Base Units by CPT Code" file, by date of service.

(2) Time Units: The way in which time units are to be calculated is set forth in Section 9789.18.8.

(3) Adjusted Anesthesia Conversion Factor is set forth in 9789.19.1, Table A applicable to the date of service.

The adjusted conversion factor for the locality corresponding to the county where the service is provided, is determined as follows:

[(Work GPCI by locality * Anesthesia Work Share) +

(Practice Expense GPCI by locality *

Anesthesia Practice Expense Share) +

(Malpractice GPCI by locality *

Anesthesia Malpractice Share)] * Anesthesia Conversion Factor].

The appropriate payment locality will be determined according to subdivision (e)(2) of section 9789.12.2.

Cal. Code Regs. Tit. 8, § 9789.18.1

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 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).

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

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 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).