Cal. Code Regs. tit. 8 § 9789.19
Current through Register 2024 Notice Reg. No. 44, November 1, 2024
Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director.
| Document | Services Rendered On or After 1/1/2014 |
| Adjustment Factors | For all services other than anesthesia: |
| (These factors have been incorporated into the conversion factors listed below) | 2014 Total RVS adjustment factor: 1.0477 |
| 2014 RVU budget neutrality factor: 1.00046 | |
| 2014 RVU rescaling adjustment factor: 1.04718 | |
| 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 | File name: 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 for Medicare Services | Copy of the 1/1/2014 Manual is posted on the DWC website: 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 Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after January 1, 2014: |
| RVU14A [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 Medicare Claims Processing: Casting and Splint Supplies | For services rendered on or after 1/1/2014, use: |
| Transmittal 2837 (Change Request 8523) | |
| 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 for MEI and Relative Value Scale adjustment factor, if any | Anesthesia Conversion Factor: $33.8190 |
| Surgery Conversion Factor: $55.2913 | |
| Radiology Conversion Factor: $53.1039 | |
| Other Services Conversion Factor: $38.3542 | |
| Current Procedural Terminology (CPT®) | CPT 2014 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412 and Surgery CF) | |
| 27216 (Use G0413 and Surgery CF) | |
| 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 Procedure CPT codes subject to the MPPR | For services rendered on or after January 1, 2014: |
| RVU14A, PPRRVU14_V1219, 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: | |
| 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 Indicator Description | For services rendered on or after January 1, 2014: |
| 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 Indicator for Procedure | For services rendered on or after January 1, 2014: |
| 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 Fee Schedule | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Health Professional Shortage Area zip code data files | 2014 Primary Care HPSA [ZIP, 97KB] |
| 2014 Mental Health HPSA [ZIP, 222KB] | |
| Health Resources and Services Administration: Geographic HPSA shortage area query | |
| (By State & County) | http://hpsafind.hrsa.gov/ |
| Health Resources and Services Administration: Geographic HPSA shortage area query | |
| (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 CPT codes subject to the MPPR | For services rendered on or after January 1, 2014: |
| RVU14A, PPRRVU14_V1219, 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 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 Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after January 1, 2014: |
| RVU14A, PPRRVU14_V1219, 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 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 Imaging Multiple Procedures | For services rendered on or after January 1, 2014: |
| RVU14A, PPRRVU14_V1219, number "4" in column S, labeled, "Mult Proc" | |
| 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 (Other than anesthesia) | Average Statewide Work GAF: 1.040 |
| 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 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, 2015 & Mid-year Updates |
| Adjustment Factors | For all services other than anesthesia: |
| (These factors have been incorporated into the conversion factors listed below) | 2015 Cumulative Relative Value Scale adjustment factor: 1.0703 |
| [2015 annual adjustment factor x 2014 cumulative adjustment factor = 2015 cumulative adjustment factor (1.006 x 1.0638 = 1.0703)] | |
| 2015 RVS adjustment factor[DAGGER]: 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[DAGGER]: 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] | |
| [DAGGER]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 CPT Code | File name: 2014anesBASEfin |
| 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 Initiative Policy Manual for Medicare Services | "NCCI Policy Manual for Medicare Services -- Effective January 1, 2015 [ZIP, 1MB]" |
| 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 (Practitioner PTP Edits) | |
| Physician CCI Edits v21.0 effective January 1, 2015 (898,800 records). The last row contains edit 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 Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after March 1, 2015: |
| RVU15A (Updated 01/08/15) [ZIP, 2MB] | |
| * 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 for MEI and Relative Value Scale adjustment factor | Anesthesia Conversion Factor: $31.5290 |
| Surgery Conversion Factor: $51.6570 | |
| Radiology Conversion Factor: $50.1900 | |
| Other Services Conversion Factor: $40.2970 | |
| Current Procedural Terminology (CPT®) | CPT 2015 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology | Do not use CPT codes: |
| CPT codes that shall not be used | 27215 (Use G0412 and Surgery CF) |
| 27216 (Use G0413 and Surgery CF) | |
| 27217 (Use G0414 and Surgery CF) | |
| 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 Procedure CPT codes subject to the MPPR | For services rendered on or after March 1, 2015: |
| RVU15A, PPRRVU15_V1223c, 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 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 Indicator Description | For services rendered on or after March 1, 2015: |
| 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 Procedures Subject to the MPPR | For services rendered on or after March 1, 2015: |
| RVU15A, PPRRVU15_V1223c, 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 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 Multiple Procedures Subject to the MPPR | For services rendered on or after March 1, 2015: |
| RVU15A, PPRRVU15_V1223c, 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 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 Schedule | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Health Professional Shortage Area zip code data files | 2015 Primary Care HPSA [ZIP, 88KB] |
| 2015 Mental Health HPSA [ZIP, 185KB] | |
| Health Resources and Services Administration: Geographic HPSA shortage area query | |
| (By State & County) | http://hpsafind.hrsa.gov/ |
| Health Resources and Services Administration: Geographic HPSA shortage area query (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 CPT codes subject to the MPPR | For services rendered on or after March 1, 2015: |
| RVU15A, PPRRVU15_V1223c, 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 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 Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after March 1, 2015: |
| RVU15A, PPRRVU15_V1223c, 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 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 than anesthesia) | Average Statewide Work GAF: 1.0420 |
| 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 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, 2016 & Mid-year Updates |
| Adjustment Factors | For services rendered on or after January 1, 2016: |
| (These factors have been incorporated into the conversion factors listed below) | For all services other than anesthesia: |
| 2016 Cumulative adjustment factor: 1.0818 | |
| 2016 RVU budget neutrality adjustment factor: 0.9998 | |
| 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 CPT Code | File name: 2014anesBASEfin |
| 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 Initiative Policy Manual for Medicare Services | "NCCI Policy Manual for Medicare Services -- Effective January 1, 2016 [ZIP, 761MB]" |
| Copy of the 2016 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, 2016: |
| Physician CCI Edits (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 Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after January 1, 2016: |
| RVU16A (Released January 2016) [ZIP, 3MB] | |
| * 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 MEI and Relative Value Scale adjustment factor | For services rendered on or after January 1, 2016: |
| Anesthesia Conversion Factor: $29.3852 | |
| 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 Terminology (CPT®) | CPT 2016 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology | Do not use CPT codes: |
| CPT codes that shall not be used | 27215 (Use G0412 and Surgery CF) |
| 27216 (Use G0413 and Surgery CF) | |
| 27217 (Use G0414 and Surgery CF) | |
| 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 Procedure CPT codes subject to the MPPR | For services rendered on or after January 1, 2016: |
| RVU16A, PPRRVU16_V0122, 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 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 Indicator Description | For services rendered on or after January 1, 2016: |
| 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 Procedures Subject to the MPPR | For services rendered on or after January 1, 2016: |
| RVU16A, PPRRVU16_V0122, number "88" in column AB, labeled, "Diagnostic Imaging Family 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, PPRRVU16_April_V0202, number "88" in column AB, labeled, "Diagnostic Imaging Family 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 July 1, 2016: | |
| RVU16C, PPRRVU16_V0517, number "88" in column AB, labeled, "Diagnostic Imaging Family 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 October 1, 2016: | |
| RVU16D, PPRRVU16_V0804, number "88" in column AB, labeled, "Diagnostic Imaging Family 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 | |
| Diagnostic Imaging Multiple Procedures Subject to the MPPR | For services rendered on or after January 1, 2016: |
| RVU16A, PPRRVU16_V0122, number "4" in column S, labeled, "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 April 1, 2016: | |
| RVU16B, PPRRVU16_April_V0202, number "4" in column S, labeled, "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, labeled, "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, labeled, "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 Schedule | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Health Professional Shortage Area zip code data files | 2016 Primary Care HPSA [ZIP, 99KB] |
| 2016 Mental Health HPSA [ZIP, 239KB] | |
| 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/ |
| Health Resources and Services Administration: Geographic HPSA shortage area query | |
| (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 CPT codes subject to the MPPR | For services rendered on or after January 1, 2016: |
| RVU16A, PPRRVU16_V0122, 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 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 Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after January 1, 2016: |
| RVU16A, PPRRVU16_V0122, 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 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 anesthesia) | Average Statewide Work GAF: 1.0420 |
| 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 conversion factors listed below) | For all services other than anesthesia: |
| 2017 Cumulative adjustment factor: 1.0933 | |
| 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 | File name: 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 Initiative Policy Manual for Medicare Services | "NCCI Policy Manual for Medicare Services -- Effective January 1, 2017 [ZIP, 770KB]" |
| 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) | Practitioner PTP Edits v23.0 effective January 1, 2017 |
| (422,052 records) 0001M/36591 -- 24940/G0471 | |
| 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 Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after March 1, 2017: |
| RVU17A (January 2017 release) [ZIP, 3MB] | |
| * 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 MEI and Relative Value Scale adjustment factor | For services rendered on or after March 1, 2017: |
| Anesthesia Conversion Factor: $26.8011 | |
| Other Services Conversion Factor: $44.6572 | |
| Current Procedural Terminology (CPT®) | CPT 2017 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412) | |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code WC005 code) | |
| 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 Procedure CPT codes subject to the MPPR | For services rendered on or after March 1, 2017: |
| RVU17A, PPRRVU17_V1219, 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 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 Indicator Description | For services rendered on or after March 1, 2017: |
| 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 Procedures Subject to the MPPR | For services rendered on or after March 1, 2017: |
| RVU17A, PPRRVU17_V1219, 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 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 Multiple Procedures Subject to the MPPR | For services rendered on or after March 1, 2017: |
| RVU17A, PPRRVU17_V1219, 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 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 Fee Schedule | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Health Professional Shortage Area zip code data files | 2017 Primary Care HPSA [ZIP, 99KB] |
| 2017 Mental Health HPSA [ZIP, 237KB] | |
| 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/ |
| Health Resources and Services Administration: Geographic HPSA shortage area query (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 CPT codes subject to the MPPR | For services rendered on or after March 1, 2017: |
| RVU17A, PPRRVU17_V1219, 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 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 Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after March 1, 2017: |
| RVU17A, PPRRVU17_V1219, 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 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 than anesthesia) | Average Statewide Work GAF: 1.0417 |
| Average Statewide Practice Expense GAF: 1.1632 | |
| Average Statewide Malpractice Expense GAF: 0.6632 | |
| Statewide GAF (Anesthesia) | Average Statewide Anesthesia GAF: 1.0374 |
| Splints and Casting Supplies | For services rendered on or after March 1, 2017, 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 January 1, 2018 & Midyear Updates |
| Adjustment Factors (These factors have been incorporated into the conversion factors listed below) | For services rendered on or after January 1, 2018: |
| For all services other than anesthesia: | |
| 2018 Cumulative adjustment factor: 1.1075 | |
| 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 CPT Code | File name: |
| cms1676f_cy_2018_anesthesia_base_units.xlsx | |
| 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 Initiative Policy Manual for Medicare Services | "NCCI Policy Manual for Medicare Services -- Effective January 1, 2018 [ZIP, 851KB]" |
| 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 Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after January 1, 2018: |
| RVU18A (Updated 12/20/2017) [ZIP, 3MB] | |
| * 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 MEI and Relative Value Scale adjustment factor | For services rendered on or after January 1, 2018: |
| Anesthesia Conversion Factor: $27.2415 | |
| Other Services Conversion Factor: $45.2371 | |
| Current Procedural Terminology (CPT®) | CPT 2018 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412) | |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code_WC005 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 Procedure CPT codes subject to the MPPR | For services rendered on or after January 1, 2018: |
| RVU18A, PPRRVU18_JAN, 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 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 Indicator Description | For services rendered on or after January 1, 2018: |
| 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 Procedures Subject to the MPPR | For services rendered on or after January 1, 2018: |
| RVU18A, PPRRVU18_JAN, 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 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 Multiple Procedures Subject to the MPPR | For services rendered on or after January 1, 2018: |
| RVU18A, PPRRVU18_JAN, 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 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 Fee Schedule | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Health Professional Shortage Area zip code data files | 2018 Primary Care HPSA [ZIP, 98KB] |
| 2018 Mental Health HPSA [ZIP, 218KB] | |
| 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/ |
| Health Resources and Services Administration: Geographic HPSA shortage area query | |
| (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 CPT codes subject to the MPPR | For services rendered on or after January 1, 2018: |
| RVU18A, PPRRVU18_JAN, 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 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 Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after January 1, 2018: |
| RVU18A, PPRRVU18_JAN, 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 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 than anesthesia) | Average Statewide Work GAF: 1.041 |
| 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 (These factors have been incorporated into the conversion factors listed below) | For all services other than anesthesia: |
| 2019 Cumulative adjustment factor: 1.1226 | |
| 2019 RVU budget neutrality adjustment factor: 0.9986 | |
| 2019 Annual increase in the MEI: 1.015 | |
| 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 CPT Code | File name: |
| cms1676f_cy_2018_anesthesia_base_units.xlsx | |
| 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: | For services rendered on or after January 1, 2019, use: |
| Medically Unlikely Edits | "Practitioner Services MUE Table -- Effective 01-01-2019 [ZIP, 350KB]," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). |
| For services rendered on or after April 1, 2019, use: | |
| "Practitioner Services MUE Table -- Effective 04-01-2019 [ZIP, 351KB]," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). | |
| For services rendered on or after July 1, 2019, use: | |
| "Practitioner Services MUE Table -- Effective 07-01-2019 [ZIP, 354KB]," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). | |
| For services rendered on or after October 1, 2019, use: | |
| "Practitioner Services MUE Table -- Effective 10-01-2019 [ZIP, 354KB]," 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#7 | |
| CCI Edits: | "NCCI Policy Manual for Medicare Services -- Effective January 1, 2019 [ZIP, 1MB]" |
| National Correct Coding Initiative Policy Manual for Medicare Services | Copy of the 2019 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, 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 | |
| For services rendered on or after April 1, 2019: | |
| Practitioner PTP Edits v25.1 effective April 1, 2019 | |
| (556,965 records) 0001M/36591 -- 26992/G0471 | |
| Practitioner PTP Edits v25.1 effective April 1, 2019 | |
| (489,643 records) 27000/01995 -- 37790/G0471 | |
| Practitioner PTP Edits v25.1 effective April 1, 2019 | |
| (529,244 records) 38100/0213T -- 61888/G0471 | |
| Practitioner PTP Edits v25.1 effective April 1, 2019 | |
| (483,364 records): 62000/0213T -- R0075/R0070 | |
| For services rendered on or after July 1, 2019: | |
| Practitioner PTP Edits v25.2 effective July 1, 2019 | |
| (561,060 records) 0001M/36591 -- 26992/G0471 | |
| Practitioner PTP Edits v25.2 effective July 1, 2019 | |
| (491,324 records) 27000/01995 -- 37799/96523 | |
| Practitioner PTP Edits v25.2 effective July 1, 2019 | |
| (531,167 records) 38100/0213T -- 61888/G0471 | |
| Practitioner PTP Edits v25.2 effective July 1, 2019 | |
| (489,591 records): 62000/0213T -- R0075/R0070 | |
| For services rendered on or after October 1, 2019: | |
| Practitioner PTP Edits v25.3 effective October 1, 2019 | |
| (561,144 records) 0001M/36591 -- 26992/G0471 | |
| Practitioner PTP Edits v25.3 effective October 1, 2019 | |
| (491,337 records) 27000/01995 -- 37799/96523 | |
| Practitioner PTP Edits v25.3 effective October 1, 2019 | |
| (531,167 records) 38100/0213T -- 61888/G0471 | |
| Practitioner PTP Edits v25.3 effective October 1, 2019 | |
| (489,612 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 Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after January 1, 2019: |
| RVU19A (updated file 12/20/18) [ZIP, 3MB] | |
| * RVU19A (Excluding Attachment A) | |
| * PPRRVU19_V1213 | |
| * OPPSCAP_Jan | |
| * 19LOCCO | |
| * GPCI2019 | |
| Excluding: | |
| ANES2019 | |
| For services rendered on or after April 1, 2019: | |
| RVU19B [ZIP, 3MB] | |
| * RVU19B (Excluding Attachment A) | |
| * PPRRVU19_APR | |
| * OPPSCAP_APR | |
| * 19LOCCO | |
| * GPCI2019 | |
| Excluding: | |
| ANES2019 | |
| For services rendered on or after July 1, 2019: | |
| RVU19C [ZIP, 3MB] | |
| * RVU19C (Excluding Attachment A) | |
| * PPRRVU19_JUL | |
| * OPPSCAP_JUL | |
| * 19LOCCO | |
| * GPCI2019 | |
| Excluding: | |
| ANES2019 | |
| For services rendered on or after October 1, 2019: | |
| RVU19D [ZIP, 3MB] | |
| * RVU19D (Excluding Attachment A) | |
| * PPRRVU19_OCT | |
| * OPPSCAP_OCT | |
| * 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 adjusted for MEI and Relative Value Scale adjustment factor | Anesthesia Conversion Factor: $27.6859 |
| Other Services Conversion Factor: $45.8513 | |
| Current Procedural Terminology (CPT®) | CPT 2019 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412) | |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code_WC005 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 Procedure CPT codes subject to the MPPR | For services rendered on or after January 1, 2019: RVU19A, PPRRVU19_V1213, number "6" in column S, labeled "Mult Proc" (Modifier 51), 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 |
| For services rendered on or after April 1, 2019: RVU19B, PPRRVU19_APR, number "6" in column S, labeled "Mult Proc" (Modifier 51), 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 | |
| For services rendered on or after July 1, 2019: RVU19C, PPRRVU19_JUL, number "6" in column S, labeled "Mult Proc" (Modifier 51), 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 | |
| For services rendered on or after October 1, 2019: RVU19D, PPRRVU19_OCT, number "6" in column S, labeled "Mult Proc" (Modifier 51), 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 Family Indicator Description | For services rendered on or after January 1, 2019: |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU19A, RVU19A (PDF document) | |
| For services rendered on or after April 1, 2019: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU19B, RVU19B (PDF document) | |
| For services rendered on or after July 1, 2019: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU19C, RVU19C (PDF document) | |
| For services rendered on or after October 1, 2019: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU19D, PPRRVU19_OCT (PDF document) | |
| Diagnostic Imaging Family Procedures Subject to the MPPR | For services rendered on or after January 1, 2019: |
| RVU19A, PPRRVU19_V1213, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," 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 | |
| For services rendered on or after April 1, 2019: RVU19B, PPRRVU19_APR, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," 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 | |
| For services rendered on or after July 1, 2019: RVU19C, PPRRVU19_JUL, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," 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 | |
| For services rendered on or after October 1, 2019: RVU19D, PPRRVU19_OCT, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," 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 Multiple Procedures Subject to the MPPR | For services rendered on or after January 1, 2019: RVU19A, PPRRVU19_V1213, number "4" in column S, labeled, "Mult Proc," 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 |
| For services rendered on or after April 1, 2019: RVU19B, PPRRVU19_APR, number "4" in column S, labeled, "Mult Proc," 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 | |
| For services rendered on or after July 1, 2019: RVU19C, PPRRVU19_JUL, number "4" in column S, labeled, "Mult Proc," 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 | |
| For services rendered on or after October 1, 2019: RVU19D, PPRRVU19_OCT, number "4" in column S, labeled, "Mult Proc," 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 Fee Schedule | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Practice Cost Index (GPCI) by locality (Other than anesthesia services) | For services rendered on or after January 1, 2019: |
| RVU19A | |
| * GPCI2019 Addendum E -- Column B ("Locality Number"), column C ("Locality Name"), column D ("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") | |
| For services rendered on or after April 1, 2019: | |
| RVU19B | |
| * GPCI2019 Addendum E -- Column B ("Locality Number"), column C ("Locality Name"), column D ("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") | |
| For services rendered on or after July 1, 2019: | |
| RVU19C | |
| * GPCI2019 Addendum E -- Column B ("Locality Number"), column C ("Locality Name"), column D ("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") | |
| For services rendered on or after October 1, 2019: | |
| RVU19D | |
| * GPCI2019 Addendum E -- Column B ("Locality Number"), column C ("Locality Name"), column D ("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 Index (GPCIs) by locality and anesthesia shares (Anesthesia) | For services rendered on or after January 1, 2019: |
| 2019 Anesthesia Conversion Factors [ZIP, 18KB] (These factors have been incorporated into the conversion 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") | |
| For services rendered on or after April 1, 2019: | |
| 2019 Anesthesia Conversion Factors [ZIP, 18KB] (These factors have been incorporated into the conversion 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 | |
| RVU19B (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") | |
| For services rendered on or after July 1, 2019: | |
| 2019 Anesthesia Conversion Factors [ZIP, 18KB] (These factors have been incorporated into the conversion 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 | |
| RVU19C (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") | |
| For services rendered on or after October 1, 2019: | |
| 2019 Anesthesia Conversion Factors [ZIP, 18KB] (These factors have been incorporated into the conversion 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 | |
| RVU19D, (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") | |
| Note: | |
| 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 Index (GPCI) locality mapping | For services rendered on or after January 1, 2019: |
| Zip Code files mapping zip codes to GPCI locality (for "other than anesthesia services" and anesthesia services) | 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 Codes requiring + 4 extension -- Revised 11/14/2018 [ZIP, 1KB], for the State of California ("CA") | |
| For services rendered on or after April 1, 2019: | |
| Zip Code to Carrier Locality File -- Revised 2/15/2019 [ZIP, 4MB], Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| Zip Codes requiring +4 extension -- Revised 2/15/2019 [ZIP, 1KB], for the State of California ("CA") | |
| For services rendered on or after July 1, 2019: | |
| Zip Code to Carrier Locality File -- Revised 05/15/2019 [ZIP, 4MB], Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| Zip Codes requiring +4 extension -- Revised 05/15/2019 [ZIP, 1KB], for the State of California ("CA") | |
| For services rendered on or after October 1, 2019: | |
| Zip Code to Carrier Locality File -- Revised 08/13/2019 [ZIP, 4MB], Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| Zip Codes requiring +4 extension -- Revised 08/13/2019 [ZIP, 1KB], for the State of California ("CA") | |
| Note: | |
| Access the Zip Code files on the DWC website: https://www.dir.ca.gov/dwc/OMFS9904.htm#7 | |
| CMS posts only the most recent version of the Zip Code files, which can be accessed on the CMS website: | |
| https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html | |
| Geographic Health Professional Shortage Area zip code data files | 2019 Primary Care HPSA [ZIP, 100KB] |
| 2019 Mental Health HPSA [ZIP, 218KB] | |
| 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/ |
| Health Resources and Services Administration: Geographic HPSA shortage area query (By Address) | http://datawarehouse.hrsa.gov/geoHPSAAdvisor/GeographicHPSAAdvisor.aspx |
| Incident To Codes | For services rendered on or after January 1, 2019: RVU19A, PPRRVU19_V1213, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) |
| For services rendered on or after April 1, 2019: RVU19B, PPRRVU19_APR, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after July 1, 2019: RVU19C, PPRRVU19_JUL, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after October 1, 2019: RVU19D, PPRRVU19_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, 2019, use: | |
| Medi-Cal Rates file -- Updated 12/15/2018 | |
| For services rendered on or after January 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 1/15/2019 | |
| For services rendered on or after February 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 2/15/2019 | |
| For services rendered on or after March 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 3/15/2019 | |
| For services rendered on or after April 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 4/15/2019 | |
| For services rendered on or after May 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 5/15/2019 | |
| For services rendered on or after June 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 6/15/2019 | |
| For services rendered on or after July 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 7/15/2019 | |
| For services rendered on or after August 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 8/15/2019 | |
| For services rendered on or after September 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 9/15/2019 | |
| For services rendered on or after October 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 10/15/2019 | |
| For services rendered on or after November 15, 2019, use: | |
| Medi-Cal Rates file -- Updated 11/15/2019 | |
| For services rendered on or after December 15, 2019, use: Medi-Cal Rates file -- Updated 12/15/2019 | |
| 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 CPT codes subject to the MPPR | For services rendered on or after January 1, 2019: |
| RVU19A, PPRRVU19_V1213, number "7" in column S, labeled "Mult Proc" (Modifier 51). 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 | |
| For services rendered on or after April 1, 2019: | |
| RVU19B, PPRRVU19_APR, number "7" in column S, labeled "Mult Proc" (Modifier 51). 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 | |
| For services rendered on or after July 1, 2019: | |
| RVU19C, PPRRVU19_JUL, number "7" in column S, labeled "Mult Proc" (Modifier 51). 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 | |
| For services rendered on or after October 1, 2019: | |
| RVU19D, PPRRVU19_OCT, number "7" in column S, labeled "Mult Proc" (Modifier 51). 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 Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after January 1, 2019: |
| RVU19A, PPRRVU19_V1213, number "5" in column S, labeled "Mult Proc." Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-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 April 1, 2019: | |
| RVU19B, PPRRVU19_APR, number "5" in column S, labeled "Mult Proc." Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-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, 2019: | |
| RVU19C, PPRRVU19_JUL, number "5" in column S, labeled "Mult Proc." Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-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, 2019: | |
| RVU19D, PPRRVU19_OCT, number "5" in column S, labeled "Mult Proc." Also listed in CY 2019 PFS Final Rule Multiple Procedure Payment Reduction Files [ZIP, 61KB], in the document CMS-1693-F_Separately Payable Therapy Services Subject to MPPR | |
| 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 |
| Document/Data | Services Rendered On or After January 1, 2020 & Mid-year Updates |
| Adjustment Factors -- Services Other than Anesthesia | For all services other than anesthesia: |
| (These factors have been incorporated into the conversion factors listed below) | 2020 RVU budget neutrality adjustment factor: 1.0014 |
| 2020 Annual increase in the MEI: 1.019 | |
| Adjustment Factors -- Anesthesia | For anesthesia services: |
| (These factors have been incorporated into the conversion factors listed on Table A 2020, RVU20A, updated 01-22-2020) | 2020 RVU budget neutrality adjustment factor: 1.0014 |
| 2020 Anesthesia practice expense and malpractice adjustment factor: 0.9954 | |
| 2020 Annual increase in the MEI: 1.019 | |
| Anesthesia Base Units by CPT Code | File name: |
| cms1676f_cy_2018_anesthesia_base_units.xlsx | |
| California-Specific Codes | WC001 -- Not reimbursable |
| WC002 -- $12.89 | |
| WC003 -- $41.84 for first page | |
| $25.73 each additional page. Maximum of six pages absent mutual agreement ($170.49) | |
| WC004 -- $41.84 for first page | |
| $25.73 each additional page. Maximum of seven pages absent mutual agreement ($196.22) | |
| WC005 -- $41.84 for first page | |
| $25.73 each additional page. Maximum of six pages absent mutual agreement ($170.49) | |
| WC007 -- $41.84 for first page | |
| $25.73 each additional page. Maximum of six pages absent mutual agreement ($170.49) | |
| WC008 -- $11.10 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
| WC009 -- $11.10 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
| WC010 -- $5.54 per x-ray | |
| WC011 -- $11.10 per scan | |
| WC012 -- No Fee Prescribed/Non Reimbursable absent agreement | |
| CCI Edits: | For services rendered on or after January 1, 2020, use: |
| Medically Unlikely Edits | "Practitioner Services MUE Table -- Effective 01-01-2020 (ZIP)," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). |
| For services rendered on or after April 1, 2020, use: | |
| "Practitioner Services MUE Table -- Replacement Effective 04-01-2020 (ZIP)," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). | |
| For services rendered on or after July 1, 2020, use: | |
| "Practitioner Services MUE Table -- Effective-07-01-2020 posted June 1, 2020 (ZIP)," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). | |
| For services rendered on or after October 1, 2020, use: | |
| "Practitioner Services MUE Table -- Effective-10-01-2020 posted September 1, 2020 (ZIP)," 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#7 | |
| CCI Edits: | "NCCI Policy Manual for Medicare Services -- Effective January 1, 2020 (ZIP)" |
| National Correct Coding Initiative Policy Manual for Medicare Services | |
| CCI Edits: | |
| Practitioner Procedure to Procedure (PTP) Edits | For services rendered on or after January 1, 2020: |
| Practitioner PTP Edits v26.0 effective January 1, 2020 | |
| (532,510 records) 0001M/36591 -- 26992/G0471 | |
| Practitioner PTP Edits v26.0 effective January 1, 2020 | |
| (529,304 records) 27000/01995 -- 37799/96523 | |
| Practitioner PTP Edits v26.0 effective January 1, 2020 | |
| (503,060 records) 38100/0213T -- 61888/G0471 | |
| Practitioner PTP Edits v26.0 effective January 1, 2020 | |
| (562,155 records): 62000/0213T -- R0075/R0070 | |
| For services rendered on or after March 13, 2020: | |
| Practitioner PTP Edits v260r2 effective January 1, 2020 | |
| (532,511 records) 0001M/36591 -- 25999/96523 | |
| Practitioner PTP Edits v260r2 effective January 1, 2020 | |
| (529,304 records) 26010/01810 -- 36909/J2001 | |
| Practitioner PTP Edits v260r2 effective January 1, 2020 | |
| (503,060 records) 37140/0213T -- 59899/96523 | |
| Practitioner PTP Edits v260r2 effective January 1, 2020 | |
| (561,874 records) 60000/0213T -- R0075/R0070 | |
| For services rendered on or after April 1, 2020: | |
| Practitioner PTP Edits v261r1 effective April 1, 2020 | |
| (532,940 records) 0001M/36591 -- 25999/96523 | |
| Practitioner PTP Edits v261r1 effective April 1, 2020 | |
| (529,534 records) 26010/01810 -- 36909/J2001 | |
| Practitioner PTP Edits v261r1 effective April 1, 2020 | |
| (503,072 records) 37140/0213T -- 59899/96523 | |
| Practitioner PTP Edits v261r1 effective April 1, 2020 | |
| (562,285 records): 60000/0213T -- R0075/R0070 | |
| For services rendered on or after July 1, 2020: | |
| Practitioner PTP Edits v262r0 effective July 1, 2020 | |
| (532,964 records) 0001M/36591 -- 25999/96523 | |
| Practitioner PTP Edits v262r0 effective July 1, 2020 | |
| (529,569 records) 26010/01810 -- 36909/J2001 | |
| Practitioner PTP Edits v262r0 effective July 1, 2020 | |
| (503,072 records) 37140/0213T -- 59899/96523 | |
| Practitioner PTP Edits v262r0 effective July 1, 2020 | |
| (562,291 records): 60000/0213T -- R0075/R0070 | |
| For services rendered on or after October 1, 2020: | |
| Practitioner PTP Edits v263r0 effective October 1, 2020 | |
| (603,809 records) 0001M/36591 -- 25999/96523 (posted 09/01/2020) | |
| Practitioner PTP Edits v263r0 effective October 1, 2020 | |
| (599,847 records) 26010/01810 -- 36909/J2001 (posted 09/01/2020) | |
| Practitioner PTP Edits v263r0 effective October 1, 2020 | |
| (580,791 records) 37140/0213T -- 60699/96523 (posted 09/01/2020) | |
| Practitioner PTP Edits v263r0 effective October 1, 2020 | |
| (634,723 records): 60000/0213T -- R0075/R0070 (posted 09/01/2020) | |
| 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 on the CMS website covers all time periods. | |
| CMS' Medicare National Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020) (ZIP) | |
| * RVU20A (Excluding Attachment A) | |
| * PPRRVU20_Jan | |
| * OPPSCAP_Jan | |
| * 20LOCCO | |
| * GPCI2020 | |
| Excluding: | |
| ANES2020 | |
| For services rendered on or after March 1, 2020, for CPT codes 99441, 99442, 99443: | |
| RVU20B (Updated 05/01/2020) (ZIP) | |
| * RVU20B-508 (Excluding Attachment A) | |
| * PPRRVU20_APR | |
| * OPPSCAP_APR | |
| * 20LOCCO | |
| * GPCI2020 | |
| Excluding: | |
| ANES2020 | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP) | |
| * RVU20B-508 (Excluding Attachment A) | |
| * PPRRVU20_APR | |
| * OPPSCAP_APR | |
| * 20LOCCO | |
| * GPCI2020 | |
| Excluding: | |
| ANES2020 | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP) | |
| * RVU20C (Excluding Attachment A) | |
| * PPRRVU20_V0618 | |
| * OPPSCAP_JUL | |
| * 20LOCCO. | |
| * GPCI2020 | |
| Excluding: | |
| ANES2020 | |
| For services rendered on or after October 1, 2020 | |
| RVU20D (ZIP) | |
| * RVU20D (Excluding Attachment A) | |
| * PPRRVU20_OCT | |
| * OPPSCAP_OCT | |
| * 20LOCCO | |
| * GPCI2020 | |
| Excluding: | |
| ANES2020 | |
| 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 adjusted for MEI and Relative Value Scale adjustment factor | Anesthesia Conversion Factor: $28.12 [See Table A 2020, RVU20A, updated 01-22-2020, Effective January 1, 2020 for GPCI-Adjusted Conversion Factors by locality] |
| Other Services Conversion Factor: $46.79 | |
| Current Procedural Terminology (CPT®) | CPT 2020 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412) | |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code WC005 code) | |
| 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 Procedure CPT codes subject to the MPPR | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020), PPRRVU20_Jan, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Cardiovascular Services Subject to MPPR. | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP), PPRRVU20_APR, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Cardiovascular Services Subject to MPPR. | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP) | |
| PPRRVU20_V0618, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Cardiovascular Services Subject to MPPR. | |
| For services rendered on or after October 1, 2020: RVU20D (ZIP) | |
| PPRRVU20_OCT, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Cardiovascular Services Subject to MPPR. | |
| Diagnostic Imaging Family Indicator Description | For services rendered on or after January 1, 2020: |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU20A (Updated 01/31/2020), RVU20A (PDF document) | |
| For services rendered on or after April 1, 2020: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU20B (Updated 05/01/2020) (ZIP), RVU20B-508 (PDF document) | |
| For services rendered on or after July 1, 2020: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU20C (Updated 06/19/2020) (ZIP), RVU20C (PDF document) | |
| For services rendered on or after October 1, 2020: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU20D (ZIP), RVU20D (PDF document) | |
| Diagnostic Imaging Family Procedures Subject to the MPPR | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020), PPRRVU20_Jan, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP), PPRRVU20_APR, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP) | |
| PPRRVU20_V0618, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR | |
| For services rendered on or after October 1, 2020: | |
| RVU20D (ZIP) | |
| PPRRVU20_OCT, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR | |
| Diagnostic Imaging Multiple Procedures Subject to the MPPR | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020), PPRRVU20_Jan, number "4" in column S, labeled, "Mult Proc," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP), PPRRVU20_APR, number "4" in column S, labeled, "Mult Proc," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP), PPRRVU20_V0618, number "4" in column S, labeled, "Mult Proc," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after October 1, 2020: | |
| RVU20D (ZIP), PPRRVU20_OCT, number "4" in column S, labeled, "Mult Proc," also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Diagnostic Imaging Services Subject to MPPR. | |
| DWC Pharmaceutical Fee Schedule | http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Practice Cost Index (GPCI) by locality (Other than anesthesia services) | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020) | |
| * GPCI2020 -- Column B ("Locality Number"), column C ("Locality Name"), column D ("2020 PW GPCI"), column E ("2020 PE GPCI"), and column F ("2020 MP GPCI") for the State of California | |
| * 20LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP) | |
| * GPCI2020 -- Column B ("Locality Number"), column C ("Locality Name"), column D ("2020 PW GPCI"), column E ("2020 PE GPCI"), and column F ("2020 MP GPCI") for the State of California | |
| * 20LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP) | |
| * GPCI2020 -- Column B ("Locality Number"), column C ("Locality Name"), column D ("2020 PW GPCI"), column E ("2020 PE GPCI"), and column F ("2020 MP GPCI") for the State of California | |
| * 20LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after October 1, 2020: | |
| RVU20D (ZIP) | |
| * GPCI2020 -- Column B ("Locality Number"), column C ("Locality Name"), column D ("2020 PW GPCI"), column E ("2020 PE GPCI"), and column F ("2020 MP GPCI") for the State of California | |
| * 20LOCCO -- 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 Index (GPCIs) by locality and anesthesia shares (Anesthesia) | For services rendered on or after January 1, 2020: |
| Section 9789.19.1, Table A 2020 RVU20A, Updated 01-22-2020, Effective January 1, 2020 incorporates the Medicare locality GPCIs into the updated locality-adjusted Anesthesia conversion factors. | |
| Medicare data utilized to derive the conversion factors on Table A Effective January 1, 2020 is as follows. | |
| 2020 Anesthesia Conversion Factors [ZIP] | |
| (CMS-1715-F_CY2020_ANES_locality adjusted_CF_withWorkFloor_09JAN2020) | |
| * Locality-specific 2020 Work GPCI, 2020 PE GPCI, 2020 MP GPCI for California as a result of the CY 2020 Final Rule, and January 9, 2020 correction to Addendum E, columns B, C, D, E, and F, excluding columns A and G labeled "Contractor" and "National Anes CF of 22.2016" [excel sheet: Locality Adjusted CFs] | |
| * Anesthesia Shares [excel sheet: Anesthesia Shares] | |
| For services rendered on or after April 1, 2020: | |
| Section 9789.19.1, Table A 2020 RVU20A, Updated 01-22-2020, remains effective for services rendered on or after April 1, 2020. | |
| For services rendered on or after July 1, 2020: | |
| Section 9789.19.1, Table A 2020 RVU20A, Updated 01-22-2020, remains effective for services rendered on or after July 1, 2020. | |
| Locality for anesthesia services determined by Medicare county to locality index. | |
| For services rendered on or after January 1, 2020: | |
| RVU20A (Updated 01/31/2020) (County to locality index) | |
| * 20LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP) (County to locality index) | |
| * 20LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP) (County to locality index) | |
| * 20LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after October 1, 2020: | |
| RVU20D (ZIP) (County to locality index) | |
| * 20LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Note: | |
| 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 Index (GPCI) locality mapping | For services rendered on or after January 1, 2020: |
| Zip Code files mapping zip codes to GPCI locality (for "other than anesthesia services" and anesthesia services) | Zip Code to Carrier Locality File -- Revised 11/19/2019 (ZIP), Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") |
| Zip Codes requiring 4 extension -- Revised 11/19/2019 (ZIP), for the State of California ("CA") | |
| For services rendered on or after April 1, 2020: | |
| Zip Code to Carrier Locality File -- Revised 02/19/2020 (ZIP), Column A ("STATE"), column B ("ZIP CODE") and column D ("LOCALITY") for the State of California ("CA") | |
| Zip Codes requiring 4 extension -- Revised 02/14/2020 (ZIP), for the State of California ("CA") | |
| For services rendered on or after July 1, 2020: | |
| Zip Code to Carrier Locality File -- Revised 05/13/2020 (ZIP), Column A ("STATE"), column B ("ZIP CODE") and column D ("LOCALITY") for the State of California ("CA") | |
| Zip Codes requiring 4 extension -- Revised 05/13/2020 (ZIP), for the State of California ("CA") | |
| For services rendered on or after October 1, 2020: | |
| Zip Code to Carrier Locality File -- Revised 08/13/2020 (ZIP), Column A ("STATE"), column B ("ZIP CODE") and column D ("LOCALITY") for the State of California ("CA") | |
| Zip Codes requiring 4 extension -- Revised 08/13/2020 (ZIP), for the State of California ("CA" | |
| Note: | |
| Access the Zip Code files on the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html | |
| Geographic Health Professional Shortage Area zip code data files | 2020 Primary Care HPSA (ZIP) |
| 2020 Mental Health HPSA (ZIP) | |
| Access the HPSA files on the CMS website: | |
| https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index | |
| Health Resources and Services Administration: Geographic HPSA shortage area query | https://data.hrsa.gov/tools/shortage-area/hpsa-find |
| (By State & County) | |
| Health Resources and Services Administration: Geographic HPSA shortage area query | https://data.hrsa.gov/tools/medicare/physician-bonus |
| (By Address) | |
| Incident To Codes | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020), PPRRVU20_Jan, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP), PPRRVU20_APR, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP), PPRRVU20_V0618, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after October 1, 2020: | |
| RVU20D (ZIP) | |
| PPRRVU20_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, 2020, use: | |
| Medi-Cal Rates file -- Updated 12/15/2019 | |
| For services rendered on or after January 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 1/15/2020 | |
| For services rendered on or after February 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 2/15/2020 | |
| For services rendered on or after March 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 3/15/2020 | |
| For services rendered on or after April 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 4/15/2020 | |
| For services rendered on or after May 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 5/15/2020 | |
| For services rendered on or after June 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 6/15/2020 | |
| For services rendered on or after July 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 7/15/2020 | |
| For services rendered on or after August 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 8/15/2020 | |
| For services rendered on or after September 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 9/15/2020 | |
| For services rendered on or after October 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 10/15/2020 | |
| For services rendered on or after November 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 11/15/2020 | |
| For services rendered on or after December 15, 2020, use: | |
| Medi-Cal Rates file -- Updated 12/15/2020 | |
| 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 CPT codes subject to the MPPR | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020), PPRRVU20_Jan, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP) in the document CMS-1715-F_CY2020_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP), PPRRVU20_APR, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP) in the document CMS-1715-F_CY2020_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after July 1, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP), PPRRVU20_V0618, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP) in the document CMS-1715-F_CY2020_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after October 1, 2020: | |
| RVU20D (ZIP) | |
| PPRRVU20_OCT, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP) in the document CMS-1715-F_CY2020_Diagnostic Ophthalmology Services Subject to MPPR | |
| Physical Therapy Multiple Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after January 1, 2020: |
| RVU20A (Updated 01/31/2020), PPRRVU20_Jan, number "5" in column S, labeled "Mult Proc." Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_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 April 1, 2020: | |
| RVU20B (Updated 05/01/2020) (ZIP), PPRRVU20_APR, number "5" in column S, labeled "Mult Proc." Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_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, 2020: | |
| RVU20C (Updated 06/19/2020) (ZIP), PPRRVU20_V0618, number "5" in column S, labeled "Mult Proc." Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_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, 2020: | |
| RVU20D (ZIP) | |
| PPRRVU20_OCT, number "5" in column S, labeled "Mult Proc." Also listed in CY 2020 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1715-F_CY2020_Separately Payable Therapy Services Subject to MPPR | |
| In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
| Physician Time | CY 2020 PFS Final Rule Physician Time (Zip) |
| Splints and Casting Supplies | The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. |
| Telehealth -- Services Accessible Through Telehealth (using audio and video telecommunication method and audio only telecommunication method) During the COVID-19 Public Health Emergency | For services on or after March 1, 2020: |
| CMS -- "Telehealth Services for PHE for the COVID-19 pandemic effective March 1 2020-updated April 30 2020" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. The list is adopted retroactively for services rendered on or after March 1, 2020. | |
| In accord with CPT 2020, append modifier 95 to procedure code when delivered via telehealth. | |
| For services on or after October 14, 2020: | |
| CMS -- "Telehealth Services for PHE for the COVID-19 pandemic effective March 1 2020-updated October 14, 2020" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. The list is adopted retroactively for services rendered on or after March 1, 2020, except that the following codes identified on the excel spreadsheet as "Added 10/14/20" are effective for services rendered on or after October 14, 2020: | |
| CPT code 93797 | |
| CPT code 93798 | |
| CPT code 93750 | |
| CPT code 95970 | |
| CPT code 95971 | |
| CPT code 95972 | |
| CPT code 95983 | |
| CPT code 95984 | |
| HCPCS code G0422 | |
| HCPCS code G0423 | |
| HCPCS code G0424 | |
| In accord with CPT 2020, append modifier 95 to procedure code when delivered via telehealth. | |
| 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, 2021 & Mid-year Updates |
| Adjustment Factors -- Services Other than Anesthesia | For all services other than anesthesia: |
| (These factors have been incorporated into the conversion factors listed below) | 2021 RVU budget neutrality adjustment factor: -6.81% (.9319) |
| 2021 Annual increase in the MEI: 1.4% (1.014) | |
| Consolidated Appropriations Act, 2021, increase of 3.75% (1.0375) | |
| Adjustment Factors -- Anesthesia | For anesthesia services: |
| (These factors have been incorporated into the conversion factors listed on Table A 2021, RVU21A (Updated 01/05/2021) Effective 03.01.2021) | 2021 RVU budget neutrality adjustment factor: -6.81% (.9319) |
| 2021 Anesthesia practice expense and malpractice adjustment factor: 0.44% (1.0044) | |
| 2021 Annual increase in the MEI: 1.4% (1.014) | |
| Consolidated Appropriations Act, 2021, increase of 3.75% (1.0375) | |
| Anesthesia Base Units by CPT Code | File name: |
| cms1676f_cy_2018_anesthesia_base_units.xlsx | |
| California-Specific Codes | WC001 -- Not reimbursable |
| WC002 -- $13.70 | |
| WC003 -- $42.43 for first page | |
| $26.09 each additional page. Maximum of six pages absent mutual agreement ($172.88) | |
| WC004 -- $42.43 for first page | |
| $26.09 each additional page. Maximum of seven pages absent mutual agreement ($198.97) | |
| WC005 -- $42.43 for first page | |
| $26.09 each additional page. Maximum of six pages absent mutual agreement ($172.88) | |
| WC007 -- $42.43 for first page | |
| $26.09 each additional page. Maximum of six pages absent mutual agreement ($172.88) | |
| WC008 -- $12.25 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
| WC009 -- $12.25 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages. | |
| WC010 -- $5.62 per x-ray | |
| WC011 -- $12.25 per scan | |
| WC012 -- No Fee Prescribed/Non Reimbursable absent agreement | |
| CCI Edits: | For services rendered on or after March 1, 2021, use: |
| Medically Unlikely Edits | "Practitioner Services MUE Table -- Effective 01-01-2021 Replacement-Posted December 14, 2020 (ZIP)," in the document "MCR MUE PractitionerServices Eff 01-01-2021 Replacement", excluding all codes listed with Practitioner Services MUE Value of "0" (zero). |
| For services rendered on or after April 1, 2021, use: | |
| "Practitioner Services MUE Table -- Effective-04-01-2021- Posted March 1, 2021 (ZIP)," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). | |
| For services rendered on or after July 1, 2021, use: | |
| "Practitioner Services MUE Table -- Effective-07-01-2021- Posted June 1, 2021 (ZIP)," excluding all codes listed with Practitioner Services MUE Value of "0" (zero). | |
| For services rendered on or after October 1, 2021, use: | |
| "Practitioner Services MUE Table -- Effective-10-01-2021 Posted September 3, 2021 (ZIP)," 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#7 | |
| CCI Edits: | NCCI Policy Manual for Medicare Services -- Revision Date January 1, 2021 |
| National Correct Coding Initiative Policy Manual for Medicare Services | Access on the CMS NCCI Policy Manual webpage |
| CCI Edits: | For services rendered on or after March 1, 2021: |
| Practitioner Procedure to Procedure (PTP) Edits | Practitioner PTP Edits v270r0 effective January 1, 2021 |
| (619,579 records) 0001M/36591 -- 25999/96523 (posted 12/01/2020) | |
| Practitioner PTP Edits v270r0 effective January 1, 2021 | |
| (605,350 records) 26010/01810 -- 36909/J2001 (posted 12/01/2020) | |
| Practitioner PTP Edits v270r0 effective January 1, 2021 | |
| (584,660 records) 37140/0213T -- 60699/96523 (posted 12/01/2020) | |
| Practitioner PTP Edits v270r0 effective January 1, 2021 | |
| (644,531 records): 60000/0213T -- R0075/R0070 (posted 12/01/2020) | |
| For services rendered on or after April 1, 2021: | |
| Practitioner PTP Edits v271r0 effective April 1, 2021 | |
| (620,263 records) 0001M/36591 -- 25999/96523 (posted 03/01/2021) | |
| Practitioner PTP Edits v271r0 effective April 1, 2021 | |
| (605,577 records) 26010/01810 -- 36909/J2001 (posted 03/01/2021) | |
| Practitioner PTP Edits v271r0 effective April 1, 2021 | |
| (584,943 records) 37140/0213T -- 60699/96523 (posted 03/01/2021) | |
| Practitioner PTP Edits v271r0 effective April 1, 2021 | |
| (644,832 records): 61000/0213T -- R0075/R0070 (posted 03/01/2021)) | |
| For services rendered on or after July 1, 2021: | |
| Practitioner PTP Edits v272r0 effective July 1, 2021 | |
| (620,389 records) 0001M/36591 -- 25999/96523 (posted 06/01/2021) | |
| Practitioner PTP Edits v272r0 effective July 1, 2021 | |
| (605,582 records) 26010/01810 -- 36909/J2001 (posted 06/01/2021) | |
| Practitioner PTP Edits v272r0 effective July 1, 2021 | |
| (584,943 records) 37140/0213T -- 60699/96523 (posted 06/01/2021) | |
| Practitioner PTP Edits v272r0 effective July 1, 2021 | |
| (644,928 records): 61000/0213T -- U0003/U0004 (posted 06/01/2021) | |
| For services rendered on or after October 1, 2021: | |
| Practitioner PTP Edits v273r2 effective October 1, 2021 | |
| (620,422 records) 0001M/36591 -- 25999/96523 (posted 10/05/2021) | |
| Practitioner PTP Edits v273r2 effective October 1, 2021 | |
| (605,586 records) 26010/01810 -- 36909/J2001 (posted 10/05/2021) | |
| Practitioner PTP Edits v273r2 effective October 1, 2021 | |
| (584,947 records) 37140/0213T -- 60699/96523 (posted 10/05/2021) | |
| Practitioner PTP Edits v273r2 effective October 1, 2021 | |
| (645,310 records): 61000/0213T -- U0003/U0004 (posted 10/05/2021) | |
| 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 on the CMS website covers all time periods. | |
| CMS' Medicare National Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP) | |
| * RVU21A (Excluding Attachment A) | |
| * PPRRVU21_Jan | |
| * OPPSCAP_Jan | |
| * 21LOCCO | |
| * GPCI2021 | |
| Excluding: | |
| ANES2021 | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP) | |
| * RVU21B (Excluding Attachment A) | |
| * PPRRVU21_APR | |
| * OPPSCAP_APR | |
| * 21LOCCO | |
| * GPCI2021 | |
| Excluding: | |
| ANES2021 | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP) | |
| * RVU21C (Excluding Attachment A) | |
| * PPRRVU21_JUL | |
| * OPPSCAP_JUL | |
| * 21LOCCO | |
| * GPCI2021 | |
| Excluding: | |
| ANES2021 | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP) | |
| * RVU21D-508 (Excluding Attachment A) | |
| * PPRRVU21_OCT | |
| * OPPSCAP_OCT | |
| * 21LOCCO | |
| * GPCI2021 | |
| Excluding: | |
| ANES2021 | |
| 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 adjusted for MEI and Relative Value Scale adjustment factors and Consolidated Appropriations Act, 2021 increase | Anesthesia Conversion Factor: $27.69 |
| [See Section 9789.19.1 Table A 2021, RVU21A updated 01.05.2021, Effective for services on or after March 1, 2021 for GPCI-Adjusted Conversion Factors by locality] | |
| Other Services Conversion Factor: $45.87 | |
| Current Procedural Terminology (CPT®) | CPT 2021 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412) | |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code WC005 code) | |
| 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) | |
| 99417 (See § 9789.12.11. Use code G2212) | |
| 99455 and 99456 | |
| Diagnostic Cardiovascular Procedure CPT codes subject to the MPPR | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP), PPRRVU21_Jan, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP), PPRRVU21_APR, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP), PPRRVU21_JUL, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP), PPRRVU21_OCT, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| Diagnostic Imaging Family Indicator Description | For services rendered on or after March 1, 2021: |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU21A (Updated 01/05/2021) (ZIP), RVU21A (PDF document) | |
| For services rendered on or after April 1, 2021: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU21B (Updated 03/02/2021) (ZIP), RVU21B (PDF document) | |
| For services rendered on or after July 1, 2021: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU21C -- Updated 06/30/2021 (ZIP), RVU21C (PDF document) | |
| For services rendered on or after October 1, 2021: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU21D (ZIP), RVU21D-508 (PDF document) | |
| Diagnostic Imaging Family Procedures Subject to the MPPR | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP), PPRRVU21_Jan, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP), PPRRVU21_APR, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP), PPRRVU21_JUL, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP), PPRRVU21_OCT, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| Diagnostic Imaging Multiple Procedures Subject to the MPPR | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP), PPRRVU21_Jan, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP), PPRRVU21_APR, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP), PPRRVU21_JUL, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP), PPRRVU21_OCT, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Imaging Services Subject to MPPR. | |
| DWC Pharmaceutical Fee Schedule | Web address: http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Practice Cost Index (GPCI) by locality (Other than anesthesia services) | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP) | |
| * GPCI2021 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2021 PW GPCI (without 1.0 Floor)"), column F ("2021 PE GPCI"), and column G ("2021 MP GPCI") for the State of California | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP), | |
| * GPCI2021 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2021 PW GPCI (without 1.0 Floor)"), column F ("2021 PE GPCI"), and column G ("2021 MP GPCI") for the State of California | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP) | |
| * GPCI2021 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2021 PW GPCI (without 1.0 Floor)"), column F ("2021 PE GPCI"), and column G ("2021 MP GPCI") for the State of California | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP) | |
| * GPCI2021 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2021 PW GPCI (without 1.0 Floor)"), column F ("2021 PE GPCI"), and column G ("2021 MP GPCI") for the State of California | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| Access the Relative Value File (ZIP) 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 Index (GPCIs) by locality and anesthesia shares (Anesthesia) | For services rendered on or after March 1, 2021: |
| Section 9789.19.1, "Table A 2021 RVU21A (Updated 01-05-2021), Effective March 1, 2021" incorporates the Medicare locality GPCIs and anesthesia shares into the updated locality-adjusted Anesthesia conversion factors. | |
| Locality determined by Medicare county to locality index. | |
| For services rendered on or after March 1, 2021: | |
| RVU21A (Updated 01/05/2021) (ZIP) (County to locality index) | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after April 1, 2021: | |
| Section 9789.19.1, "Table A 2021 RVU21A (Updated 01-05-2021), Effective March 1, 2021" remains effective for services rendered on or after April 1, 2021. | |
| Locality determined by Medicare county to locality index. | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP) (County to locality index) | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP) (County to locality index) | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP) (County to locality index) | |
| * 21LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Also, see Zip Code mapping files listed below. | |
| Geographic Practice Cost Index (GPCI) locality mapping | For services rendered on or after March 1, 2021: |
| Zip Code files mapping zip codes to GPCI locality (for "other than anesthesia services" and anesthesia services) | "Zip Code to Carrier Locality File -- Revised 11/13/2020" (ZIP), in the document "ZIP5_JAN2021": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") |
| "Zip Codes requiring 4 extension -- Revised 11/13/2020" (ZIP) in the document: "ZIP5 requiring +4ext_dec2020_jan2021", for the State of California ("CA") | |
| For services rendered on or after April 1, 2021: | |
| "Zip Code to Carrier Locality File -- Revised 02/18/2021 (ZIP)", in the document "ZIP5 APR2021": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 02/17/2021 (ZIP)" in the document: "ZIP5_requring +4ext_apr2021.txt", for the State of California ("CA") | |
| For services rendered on or after July 1, 2021: | |
| "Zip Code to Carrier Locality File -- Revised 06/07/2021 (ZIP)", in the document "ZIP5 JUL2021": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 05/14/2021 (ZIP)" in the document: "ZIP5 requring +4ext_jul2021", for the State of California ("CA") | |
| For services rendered on or after October 1, 2021: | |
| "Zip Code to Carrier Locality File -- Revised 08/13/2021 (ZIP)", in the document "ZIP5 OCT2021": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 05/14/2021 (ZIP)" in the document: "ZIP5_requring +4ext_jul2021", for the State of California ("CA") | |
| Note: | |
| Access the Zip Code files on the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html | |
| Geographic Health Professional Shortage Area zip code data files | 2021 Primary Care HPSA (ZIP) |
| 2021 Mental Health HPSA (ZIP) | |
| Access the HPSA files on the CMS website: | |
| https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index | |
| Health Resources and Services Administration: Geographic HPSA shortage area query | Web address: https://data.hrsa.gov/tools/shortage-area/hpsa-find |
| (By State & County) | |
| Health Resources and Services Administration: Geographic HPSA shortage area query | Web address: https://data.hrsa.gov/tools/medicare/physician-bonus |
| (By Address) | |
| Incident To Codes | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP), PPRRVU21_Jan, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP), PPRRVU21_APR, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP), PPRRVU21_JUL, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP), PPRRVU21_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, 2021, use: | |
| Medi-Cal Rates file -- Updated 2/16/2021 | |
| For services rendered on or after March 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 3/15/2021 | |
| For services rendered on or after April 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 4/15/2021 | |
| For services rendered on or after May 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 5/15/2021 | |
| For services rendered on or after June 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 6/15/2021 | |
| For services rendered on or after July 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 7/15/2021 | |
| For services rendered on or after August 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 8/15/2021 | |
| For services rendered on or after September 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 9/15/2021 | |
| For services rendered on or after October 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 10/15/2021 | |
| For services rendered on or after November 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 11/15/2021 | |
| For services rendered on or after December 15, 2021, use: | |
| Medi-Cal Rates file -- Updated 12/15/2021 | |
| 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 CPT codes subject to the MPPR | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP), PPRRVU21_Jan, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP), PPRRVU21_APR, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after July 1, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP), PPRRVU21_JUL, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after October 1, 2021: | |
| RVU21D (ZIP), PPRRVU21_OCT, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| Physical Therapy Multiple Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after March 1, 2021: |
| RVU21A (Updated 01/05/2021) (ZIP), PPRRVU21_Jan, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-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 April 1, 2021: | |
| RVU21B (Updated 03/02/2021) (ZIP), PPRRVU21_APR, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-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, 2021: | |
| RVU21C -- Updated 06/30/2021 (ZIP), PPRRVU21_JUL, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-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, 2021: | |
| RVU21D (ZIP), PPRRVU21_OCT, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2021 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1734-F_Separately Payable Therapy Services Subject to MPPR. | |
| In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
| Physician Time | CY 2021 PFS Final Rule Physician Time (Zip) |
| Splints and Casting Supplies | The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. |
| Telehealth -- Services Accessible Through Telehealth (using audio and video telecommunication method and audio only telecommunication method) During the COVID-19 Public Health Emergency | For services rendered on or after March 1, 2021: |
| CY 2021 PFS Final Rule List of Medicare Telehealth Services (updated 12/21/2020) (ZIP) | |
| For services rendered on or after April 1, 2021: | |
| List of Telehealth Services for Calendar Year 2021 (ZIP) -- Updated 04/07/2021 in the document "List of Telehealth Services for Calendar Year UPDATED 033021_A" | |
| For services rendered on or after August 1, 2021: | |
| List of Telehealth Services for Calendar Year 2021 (ZIP) -- Updated 07/19/2021 in the document "List of Telehealth Services for Calendar Year 2021 UPDATED 10May2021" | |
| For services rendered on or after October 1, 2021: | |
| List of Telehealth Services for Calendar Year 2021 (ZIP) -- Updated 08/17/2021 in the document "List of Telehealth Services for Calendar Year 2021 UPDATED 12August2021" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. | |
| In accord with CPT 2021, append modifier 95 to procedure code when delivered via telehealth. |
| Document/Data | Services Rendered On or After January 1, 2022 & Mid-year Updates |
| Adjustment Factors -- Services Other than Anesthesia | For all services other than anesthesia: |
| (These factors have been incorporated into the conversion factor listed below) | 2022 RVU budget neutrality adjustment factor: -0.10% (0.9990) |
| 2022 Annual increase in the MEI: 2.1% (1.021) | |
| Protecting Medicare and American Farmers from Sequester Cuts Act, Public Law 117-71 increase of 3% for CY 2022 (1.03) | |
| Adjustment Factors -- Anesthesia | For anesthesia services: |
| (These factors have been incorporated into the conversion factors listed on section 9789.19.1 Table A 2022) | 2022 RVU budget neutrality adjustment factor: -0.10% (0.9990) |
| 2022 Anesthesia practice expense and malpractice adjustment factor: 0.84% (1.0084) | |
| 2022 Annual increase in the MEI: 2.1% (1.021) | |
| Protecting Medicare and American Farmers from Sequester Cuts Act, Public Law 117-71 increase of 3% for CY 2022 (1.03) | |
| Anesthesia Base Units by CPT Code | File name: CY_2022_Anesthesia_Base_Units_110921 |
| California-Specific Codes | WC001 -- Not reimbursable |
| WC002 -- $13.99 | |
| WC003 -- $43.32 for first page | |
| $26.64 each additional page. Maximum of six pages absent mutual agreement ($176.52) | |
| WC004 -- $43.32 for first page | |
| $26.64 each additional page. Maximum of seven pages absent mutual agreement ($203.16) | |
| WC005 -- $43.32 for first page | |
| $26.64 each additional page. Maximum of six pages absent mutual agreement ($176.52) | |
| WC007 -- $43.32 for first page | |
| $26.64 each additional page. Maximum of six pages absent mutual agreement ($176.52) | |
| WC008 -- $12.51 for up to the first 15 pages. $0.26 for each additional page after the first 15 pages. | |
| WC009 -- $12.51 for up to the first 15 pages. $0.26 for each additional page after the first 15 pages. | |
| WC010 -- $5.74 per x-ray | |
| WC011 -- $12.51 per scan | |
| WC012 -- No Fee Prescribed/Non Reimbursable absent agreement | |
| CMS' Medicare National Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP) | |
| * RVU22A (Excluding Attachment A) | |
| * PPRRVU22_Jan | |
| * OPPSCAP_Jan | |
| * 22LOCCO | |
| * GPCI2022 | |
| Excluding: | |
| ANES2022 | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP) | |
| * RVU22B (Excluding Attachment A) | |
| * PPRRVU22_APR | |
| * OPPSCAP_APR | |
| * 22LOCCO | |
| * GPCI2022 | |
| Excluding: | |
| ANES2022 | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP) | |
| * RVU22C (Excluding Attachment A) | |
| * PPRRVU22_JUL | |
| * OPPSCAP_JUL | |
| * 22LOCCO | |
| * GPCI2022 | |
| Excluding: | |
| ANES2022 | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (ZIP) | |
| * RVU22D (Excluding Attachment A) | |
| * PPRRVU22_OCT | |
| * OPPSCAP_OCT | |
| * 22LOCCO | |
| * GPCI2022 | |
| Excluding: | |
| ANES2022 | |
| 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 adjusted for MEI, Relative Value Scale adjustment factors, and application of Protecting Medicare and American Farmers From Sequester Cuts Act increase of 3% for CY 2022 | Anesthesia Conversion Factor: $28.28 |
| [See Section 9789.19.1 Table A 2022, Effective for services on or after January 1, 2022 for GPCI-Adjusted Conversion Factors by locality] | |
| Other Services Conversion Factor: $46.45 | |
| Current Procedural Terminology (CPT®) | CPT 2022 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology | Do not use CPT codes: |
| CPT codes that shall not be used | 27215 (Use G0412) |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code WC005 code) | |
| 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) | |
| 99417 (See § 9789.12.11. Use code G2212) | |
| 99455 and 99456 | |
| Diagnostic Cardiovascular Procedure CPT codes subject to the MPPR | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP), PPRRVU22_Jan, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP), PPRRVU22_APR, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP), PPRRVU22_JUL, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (ZIP), PPRRVU22_OCT, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| Diagnostic Imaging Family Indicator Description | For services rendered on or after January 1, 2022: |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU22A (ZIP), RVU22A (PDF document) | |
| For services rendered on or after April 1, 2022: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU22B (ZIP), RVU22B (PDF document) | |
| For services rendered on or after July 1, 2022: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU22C -- Updated 06/17/2022 (ZIP), RVU22C (PDF document) | |
| For services rendered on or after October 1, 2022: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU22D (ZIP), RVU22D (PDF document) | |
| Diagnostic Imaging Family Procedures Subject to the MPPR | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP), PPRRVU22_Jan, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP), PPRRVU22_APR, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP), PPRRVU22_JUL, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (ZIP), PPRRVU22_OCT, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| Diagnostic Imaging Multiple Procedures Subject to the MPPR | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP), PPRRVU22_Jan, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP), PPRRVU22_APR, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP), PPRRVU22_JUL, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (ZIP), PPRRVU22_OCT, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Imaging Services Subject to MPPR. | |
| DWC Pharmaceutical Fee Schedule | Web address: http://www.dir.ca.gov/dwc/OMFS9904.htm#8 |
| Geographic Practice Cost Index (GPCI) by locality (Other than anesthesia services) | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP) | |
| * GPCI2022 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2022 PW GPCI (without 1.0 Floor)"), column F ("2022 PE GPCI"), and column G ("2022 MP GPCI") for the State of California | |
| * 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP) | |
| * GPCI2022 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2022 PW GPCI (without 1.0 Floor)"), column F ("2022 PE GPCI"), and column G ("2022 MP GPCI") for the State of California | |
| * 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP) | |
| * GPCI2022 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2022 PW GPCI (without 1.0 Floor)"), column F ("2022 PE GPCI"), and column G ("2022 MP GPCI") for the State of California | |
| * 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (ZIP) | |
| * GPCI2022 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2022 PW GPCI (without 1.0 Floor)"), column F ("2022 PE GPCI"), and column G ("2022 MP GPCI") for the State of California | |
| * 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| Access the Relative Value File (ZIP) 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 Index (GPCIs) by locality and anesthesia shares (Anesthesia) | For services rendered on or after January 1, 2022: |
| Section 9789.19.1 Table A 2022, effective January 1, 2022 incorporates the Medicare locality GPCIs and anesthesia shares into updated locality-adjusted Anesthesia conversion factors. | |
| Locality determined by Medicare county to locality index. | |
| For services rendered on or after January 1, 2022: | |
| RVU22A (ZIP) (County to locality index) | |
| * 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP) (County to locality index) | |
| 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP) (County to locality index) | |
| 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (County to locality index) | |
| 22LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Also, see Zip Code mapping files listed below. | |
| Geographic Practice Cost Index (GPCI) locality mapping | For services rendered on or after January 1, 2022: |
| Zip Code files mapping zip codes to GPCI locality (for "other than anesthesia services" and anesthesia services) | "Zip Code to Carrier Locality File -- Revised 11/15/2021" (ZIP), in the document "ZIP5_JAN22": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") |
| "Zip Codes requiring 4 extension -- Revised 11/15/2021" (ZIP) in the document: "ZIP5_requiring +4ext_dec2021_jan22", for the State of California ("CA") | |
| For services rendered on or after April 1, 2022: | |
| "Zip Code to Carrier Locality File -- Revised 03/04/2022" (ZIP), in the document "ZIP5_JAN22": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 02/15/2022" (ZIP) in the document: "ZIP5_requiring +4ext_dec2021_jan22", for the State of California ("CA") | |
| For services rendered on or after July 1, 2022: | |
| "Zip Code to Carrier Locality File -- Revised 05/13/2022" (ZIP), in the document "ZIP5_JUL22": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 05/13/2022" (ZIP) in the document: "ZIP5_requiring +4ext_jul22", for the State of California ("CA") | |
| For services rendered on or after October 1, 2022: | |
| "Zip Code to Carrier Locality File -- Revised 08/23/2022" (ZIP), folder name "ZPLC_OCT2022_v2", in the document "ZIP5_OCT2022_v2": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 08/15/2022" (ZIP), folder name "ZIP5_requiring +4ext_oct22", in the document: "ZIP5_requiring +4ext_oct22", for the State of California ("CA") | |
| Note: | |
| Access the Zip Code files on the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html | |
| Geographic Health Professional Shortage Area zip code data files | 2022 Primary Care HPSA (ZIP) |
| 2022 Mental Health HPSA (ZIP) | |
| Access the HPSA files on the CMS website: | |
| https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses | |
| Health Resources and Services Administration: Geographic HPSA shortage area query (By State & County) | Web address: |
| https://data.hrsa.gov/tools/shortage-area/hpsa-find | |
| Health Resources and Services Administration: Geographic HPSA shortage area query (By Address) | Web address: |
| https://data.hrsa.gov/tools/medicare/physician-bonus | |
| Incident To Codes | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP), PPRRVU22_Jan, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP), PPRRVU22_APR, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP), PPRRVU22_JUL, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (ZIP), PPRRVU22_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, 2022: Medi-Cal Rates file -- Updated 12/15/2021 | |
| For services rendered on or after January 15, 2022: Medi-Cal Rates file -- Updated 1/15/2022 | |
| For services rendered on or after February 15, 2022: Medi-Cal Rates file -- Updated 2/15/2022 | |
| For services rendered on or after March 15, 2022: Medi-Cal Rates file -- Updated 3/15/2022 | |
| For services rendered on or after April 15, 2022: Medi-Cal Rates file -- Updated 4/15/2022 | |
| For services rendered on or after May 15, 2022: Medi-Cal Rates file -- Updated 5/15/2022 | |
| For services rendered on or after June 15, 2022: Medi-Cal Rates file -- Updated 6/15/2022 | |
| For services rendered on or after July 15, 2022: Medi-Cal Rates file -- Updated 7/15/2022 | |
| For services rendered on or after August 15, 2022: Medi-Cal Rates file -- Updated 8/15/2022 | |
| For services rendered on or after September 15, 2022: Medi-Cal Rates file -- Updated 9/15/2022 | |
| For services rendered on or after October 15, 2022: Medi-Cal Rates file -- Updated 10/15/2022 | |
| For services rendered on or after November 15, 2022: Medi-Cal Rates file -- Updated 11/15/2022 | |
| For services rendered on or after December 15, 2022: Medi-Cal Rates file -- Updated 12/15/2022 | |
| For services rendered on or after January 15, 2023: Medi-Cal Rates file -- Updated 1/15/2023 | |
| The Medi-Cal Rates file can be accessed each month on the Medi-Cal Rates home page. Excerpts of the Medi-Cal Rates files are posted on the DWC website: https://www.dir.ca.gov/dwc/FeeSchedules/Physician/Medi-Cal.asp | |
| National Correct Coding Initiative (NCCI) Edits: | For services rendered on or after January 1, 2022: |
| Medically Unlikely Edits | "Practitioner Services MUE Table -- Effective 01-01-2022 -Posted December 15, 2021 (ZIP)," in the document "MCR_MUE_PractitionerServices_Eff_01-01-2022", excluding all codes listed with Practitioner Services MUE Value of "0" (zero) |
| For services rendered on or after April 1, 2022: | |
| "Practitioner Services MUE Table -- Effective 04-01-2022 -- Posted March 1, 2022 (ZIP)," in the document "MCR_MUE_PractitionerServices_Eff_04-01-2022", excluding all codes listed with Practitioner Services MUE Value of "0" (zero) | |
| For services rendered on or after July 1, 2022: | |
| "Practitioner Services MUE Table -- Effective 07-01-2022 -- Posted June 1, 2022 (ZIP)," in the document "MCR_MUE_PractitionerServices_Eff_07-01-2022", excluding all codes listed with Practitioner Services MUE Value of "0" (zero) | |
| For services rendered on or after October 1, 2022: | |
| "Practitioner Services MUE Table (ZIP)" -- Effective Oct. 1, 2022; Posted Aug. 31, 2022, in the document "MCR_MUE_PractitionerServices_Eff_10-01-2022", 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#7 | |
| National Correct Coding Initiative (NCCI) Edits: | NCCI Policy Manual for Medicare Services -- Revision Date January 1, 2022 |
| National Correct Coding Initiative Policy Manual for Medicare Services | Access on the CMS NCCI Policy Manual webpage |
| National Correct Coding Initiative (NCCI) Edits: | For services rendered on or after January 1, 2022: |
| Practitioner Procedure to Procedure (PTP) Edits | Practitioner PTP Edits v280r1 effective January 1, 2022 |
| (639,319 records) 0001A/0591T -- 25999/96523 (posted 12/16/2021) | |
| Practitioner PTP Edits v280r1 effective January 1, 2022 | |
| (611,489 records) 26010/01810 -- 36909/J2001 (posted 12/16/2021) | |
| Practitioner PTP Edits v280r1 effective January 1, 2022 | |
| (590,131 records) 37140/0213T -- 60699/96523 (posted 12/16/2021) | |
| Practitioner PTP Edits v280r1 effective January 1, 2022 | |
| (661,916 records): 61000/0213T -- U0003/U0004 (posted 12/16/2021) | |
| For services rendered on or after February 15, 2022: | |
| Practitioner PTP Edits v280r2 effective January 1, 2022 | |
| (639,319 records) 0001A/0591T -- 25999/96523 (posted 02/04/2022) | |
| Practitioner PTP Edits v280r2 effective January 1, 2022 | |
| (611,489 records) 26010/01810 -- 36909/J2001 (posted 02/04/2022) | |
| Practitioner PTP Edits v280r2 effective January 1, 2022 | |
| (590,131 records) 37140/0213T -- 60699/96523 (posted 02/04/2022) | |
| Practitioner PTP Edits v280r2 effective January 1, 2022 | |
| (661,916 records): 61000/0213T -- U0003/U0004 (posted 02/04/2022) | |
| For services rendered on or after April 1, 2022: | |
| Practitioner PTP Edits v281r0 effective April 1, 2022 | |
| (642,540 records) 0001A/0591T -- 25999/96523 (posted 03/01/2022) | |
| Practitioner PTP Edits v281r0 effective April 1, 2022 | |
| (611,492 records) 26010/01810 -- 36909/J2001 (posted 03/01/2022) | |
| Practitioner PTP Edits v281r0 effective April 1, 2022 | |
| (590,215 records) 37140/0213T -- 60699/96523 (posted 03/01/2022) | |
| Practitioner PTP Edits v281r0 effective April 1, 2022 | |
| (662,677 records) 61000/0213T -- U0003/U0004 (posted 03/01/2022) | |
| For services rendered on or after July 1, 2022: | |
| Practitioner PTP Edits v282r0 effective July 1, 2022 | |
| (642,678 records) 0001A/0591T -- 25999/96523 (posted 6/10/2022) | |
| Practitioner PTP Edits v282r0 effective July 1, 2022 | |
| (611,492 records) 26010/01810 -- 36909/J2001 (posted 6/10/2022) | |
| Practitioner PTP Edits v282r0 effective July 1, 2022 | |
| (590,254 records) 37140/0213T -- 60699/96523 (posted 6/10/2022) | |
| Practitioner PTP Edits v282r0 effective July 1, 2022 | |
| (663,766 records) 61000/0213T -- U0003/U0004 (posted 6/10/2022) | |
| For services rendered on or after October 1, 2022: | |
| Practitioner PTP Edits v283r0 (642,695 records) 0001A/0591T -- 25999/96523 (ZIP) -- Effective Oct. 1, 2022; Posted Aug. 31, 2022 | |
| Practitioner PTP Edits v283r0 (611,803 records) 26010/01810 -- 36909/J2001 (ZIP) -- Effective Oct. 1, 2022; Posted Aug. 31, 2022 | |
| Practitioner PTP Edits v283r0 (590,308 records) 37140/0213T -- 60699/96523 (ZIP) -- Effective Oct. 1, 2022; Posted Aug. 31, 2022 | |
| Practitioner PTP Edits v283r0 (663,947 records) 61000/0213T -- U0003/U0004 (ZIP) -- Effective Oct. 1, 2022; Posted Aug. 31, 2022 | |
| Access the Practitioner PTP Edits on the CMS website: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/PTP-Coding-Edits | |
| 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 on the CMS website covers all time periods. | |
| Ophthalmology Procedure CPT codes subject to the MPPR | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP), PPRRVU22_JAN, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after April 1, 2022: | |
| RVU22B (ZIP), PPRRVU22_APR, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after July 1, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP), PPRRVU22_JUL, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after October 1, 2022: | |
| RVU22D (ZIP), PPRRVU22_OCT, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| Physical Therapy Multiple Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after January 1, 2022: |
| RVU22A (ZIP), PPRRVU22_JAN, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-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 April 1, 2022: | |
| RVU22B (ZIP), PPRRVU22_APR, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-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, 2022: | |
| RVU22C -- Updated 06/17/2022 (ZIP), PPRRVU22_JUL, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-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, 2022: | |
| RVU22D (ZIP), PPRRVU22_OCT, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2022 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1751-F_Separately Payable Therapy Services Subject to MPPR. | |
| In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
| Physician Time | CY 2022 PFS Final Rule Physician Time (Zip) |
| Splints and Casting Supplies | The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. |
| Telehealth -- Services Accessible Through Telehealth (using audio and video telecommunication method and audio only telecommunication method) During the COVID-19 Public Health Emergency | For services rendered on or after January 1, 2022: |
| List of Telehealth Services for Calendar Year 2022 (ZIP) -- Updated 01/05/2022 in the document "List of Telehealth Services 2022 Updated 05Jan2022" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. | |
| In accord with CPT 2022, append modifier 95 to procedure code when delivered via telehealth. | |
| For services rendered on or after July 1, 2022: | |
| List of Telehealth Services for Calendar Year 2022 (ZIP) -- Updated 06/17/2022 in the document "List of Telehealth Services_2022_Updated 16Jun2022" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. | |
| In accord with CPT 2022, append modifier 95 to procedure code when delivered via telehealth. |
| Document/Data | Services Rendered On or After February 15, 2023 & Mid-year Updates |
| Adjustment Factors -- Services Other than Anesthesia | For all services other than anesthesia: |
| (These factors have been incorporated into the conversion factor listed below) | 2023 RVU budget neutrality adjustment factor: -1.60% (0.9840) |
| 2023 Annual increase in the MEI: 3.8% (1.038) | |
| Consolidated Appropriations Act, 2023, increase of 2.5% (1.025) | |
| Adjustment Factors -- Anesthesia | For anesthesia services: |
| (These factors have been incorporated into the conversion factors listed on section 9789.19.1 Table A 2022) | 2023 RVU budget neutrality adjustment factor: -1.60% (0.9840) |
| 2023 Anesthesia practice expense and malpractice adjustment factor: 0.05% (1.0005) | |
| 2023 Annual increase in the MEI: 3.8% (1.038) | |
| Consolidated Appropriations Act, 2023, increase of 2.5% (1.025) | |
| Anesthesia Base Units by CPT Code | File name: CY_2022_Anesthesia_Base_Units_110921 |
| California-Specific Codes | WC001 -- Not reimbursable |
| WC002 -- $14.52 | |
| WC003 -- $44.97 for first page | |
| $27.65 each additional page. Maximum of six pages absent mutual agreement ($183.22) | |
| WC004 -- $44.97 for first page | |
| $27.65 each additional page. Maximum of seven pages absent mutual agreement ($210.87) | |
| WC005 -- $44.97 for first page | |
| $27.65 each additional page. Maximum of six pages absent mutual agreement ($183.22) | |
| WC007 -- $44.97 for first page | |
| $27.65 each additional page. Maximum of six pages absent mutual agreement ($183.22) | |
| WC008 -- $12.99 for up to the first 15 pages. $0.27 for each additional page after the first 15 pages. | |
| WC009 -- $12.99 for up to the first 15 pages. $0.27 for each additional page after the first 15 pages. | |
| WC010 -- $5.96 per x-ray | |
| WC011 -- $12.99 per scan | |
| WC012 -- No Fee Prescribed/Non Reimbursable absent agreement | |
| CMS' Medicare National Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP) | |
| * RVU23A (Excluding Attachment A) | |
| * PPRRVU23_Jan | |
| * OPPSCAP_Jan | |
| * 23LOCCO | |
| * GPCI2023 | |
| Excluding: | |
| ANES2023 | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP) | |
| * RVU23B (Excluding Attachment A) | |
| * PPRRVU23_APR | |
| * OPPSCAP_APR | |
| * 23LOCCO | |
| * GPCI2023 | |
| Excluding: | |
| ANES2023 | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP) | |
| * RVU23C (Excluding Attachment A) | |
| * PPRRVU23_JUL | |
| * OPPSCAP_JUL | |
| * 23LOCCO | |
| * GPCI2023 | |
| Excluding: | |
| ANES2023 | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP) | |
| * RVU23D (Excluding Attachment A) | |
| * PPRRVU23_OCT | |
| * OPPSCAP_OCT | |
| * 23LOCCO | |
| * GPCI2023 | |
| Excluding: | |
| ANES2023 | |
| Access the Relative Value File on the CMS website: https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files | |
| Conversion Factors adjusted for MEI, Relative Value Scale adjustment factors, and application of Consolidated Appropriations Act, 2023, increase | Anesthesia Conversion Factor: $28.75 |
| [See Section 9789.19.1 Table A effective 2.15.2023, Effective for services on or after February 15, 2023 for GPCI-Adjusted Conversion Factors by locality] | |
| Other Services Conversion Factor: $47.21 | |
| Current Procedural Terminology (CPT®) | CPT 2023 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412) | |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code WC005 code) | |
| 97014 (Use G0283) | |
| 99075 (see Medical-Legal fee schedule, § 9795) | |
| 99080 (see § 9789.14) | |
| 99242 through 99245 (see § 9789.12.12) | |
| 99252 through 99255 (see § 9789.12.12) | |
| 99417 (See § 9789.12.11. Use code G2212) | |
| 99455 and 99456 | |
| Diagnostic Cardiovascular Procedure CPT codes subject to the MPPR | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP), PPRRVU23_Jan, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP), PPRRVU23_APR, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP), PPRRVU23_JUL, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP), PPRRVU23_OCT, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| Diagnostic Imaging Family Indicator Description | For services rendered on or after February 15, 2023: |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU23A -- Updated 01/18/23 (ZIP), RVU23A (PDF document) | |
| For services rendered on or after April 1, 2023: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU23B -- Updated 02/27/23 (ZIP), RVU23B (PDF document) | |
| For services rendered on or after July 1, 2023: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU23C (ZIP), RVU23C (PDF document) | |
| For services rendered on or after October 1, 2023: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction of the TC diagnostic imaging | |
| 99 = Concept does not apply | |
| RVU23D (ZIP), RVU23D (PDF document) | |
| Diagnostic Imaging Family Procedures Subject to the MPPR | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP), PPRRVU23_Jan, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP), PPRRVU23_APR, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP), PPRRVU23_JUL, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP), PPRRVU23_OCT, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| Diagnostic Imaging Multiple Procedures Subject to the MPPR | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP), PPRRVU23_Jan, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP), PPRRVU23_APR, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP), PPRRVU23_JUL, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP), PPRRVU23_OCT, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Imaging Services Subject to MPPR. | |
| DWC Pharmaceutical Fee Schedule | Web address: |
| http://www.dir.ca.gov/dwc/OMFS9904.htm#8 | |
| Geographic Practice Cost Index (GPCI) by locality (Other than anesthesia services) | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP) | |
| * GPCI2023 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2023 PW GPCI (with 1.0 Floor)"), column F ("2023 PE GPCI"), and column G ("2023 MP GPCI") for the State of California | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP) | |
| * GPCI2023 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2023 PW GPCI (with 1.0 Floor)"), column F ("2023 PE GPCI"), and column G ("2023 MP GPCI") for the State of California | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP) | |
| * GPCI2023 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2023 PW GPCI (with 1.0 Floor)"), column F ("2023 PE GPCI"), and column G ("2023 MP GPCI") for the State of California | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP) | |
| * GPCI2023 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2023 PW GPCI (with 1.0 Floor)"), column F ("2023 PE GPCI"), and column G ("2023 MP GPCI") for the State of California | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| Access the Relative Value File (ZIP) 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 Index (GPCIs) by locality and anesthesia shares (Anesthesia) | For services rendered on or after February 15, 2023: |
| Section 9789.19.1 Table A effective 2.15.2023 incorporates the Medicare locality GPCIs and anesthesia shares into updated locality-adjusted Anesthesia conversion factors. | |
| Locality determined by Medicare county to locality index. | |
| For services rendered on or after February 15, 2023: | |
| RVU23A -- Updated 01/18/23 (ZIP) (County to locality index) | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Also, see Zip Code mapping files listed below. | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP) (County to locality index) | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Also, see Zip Code mapping files listed below. | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP) (County to locality index) | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Also, see Zip Code mapping files listed below. | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP) (County to locality index) | |
| * 23LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Also, see Zip Code mapping files listed below. | |
| Geographic Practice Cost Index (GPCI) locality mapping | For services rendered on or after February 15, 2023: |
| Zip Code files mapping zip codes to GPCI locality (for "other than anesthesia services" and anesthesia services) | "Zip Code to Carrier Locality File -- Revised 11/15/2022" (ZIP), in the document "ZIP5_JAN23": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") |
| "Zip Codes requiring 4 extension -- Revised 11/15/2022" (ZIP) in the document: "ZIP5_requiring +4ext_dec2022_jan23", for the State of California ("CA") | |
| For services rendered on or after April 1, 2023: | |
| "Zip Code to Carrier Locality File -- Revised 02/17/2023" (ZIP), in the document "ZIP5_APR23": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 02/17/2023" (ZIP) in the document: "ZIP5_requiring +4ext_apr23", for the State of California ("CA") | |
| For services rendered on or after July 1, 2023: | |
| "Zip Code to Carrier Locality File -- Revised 05/16/2023" (ZIP), in the document "ZIP5_JUL23": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 05/16/2023" (ZIP) in the document: "ZIP5_requiring +4ext_jul23", for the State of California ("CA") | |
| For services rendered on or after October 1, 2023: | |
| "Zip Code to Carrier Locality File -- Revised 08/16/2023" (ZIP), in the document "ZIP5_OCT2023": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 08/16/2023" (ZIP) in the document: "ZIP5_requiring +4ext_oct23", for the State of California ("CA") | |
| Note: | |
| Access the Zip Code files on the CMS website: https://www.cms.gov/medicare/payment/prospective-payment-systems | |
| Geographic Health Professional Shortage Area zip code data files | 2023 Primary Care HPSA (ZIP) |
| 2023 Mental Health HPSA (ZIP) | |
| Access the HPSA files on the CMS website: | |
| https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses | |
| Health Resources and Services Administration: Geographic HPSA shortage area query (By State & County) | Web address:https://data.hrsa.gov/tools/shortage-area/hpsa-find |
| Health Resources and Services Administration: Geographic HPSA shortage area query (By Address) | Web address:https://data.hrsa.gov/tools/medicare/physician-bonus |
| Incident To Codes | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP), PPRRVU23_JAN, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP), PPRRVU23 APR, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP), PPRRVU23_JUL, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP), PPRRVU23_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 February 15, 2023: | |
| Medi-Cal Rates file -- Updated 2/15/2023 | |
| For services rendered on or after March 15, 2023: | |
| Medi-Cal Rates file -- Updated 3/15/2023 | |
| For services rendered on or after April 15, 2023: | |
| Medi-Cal Rates file -- Updated 4/15/2023 | |
| For services rendered on or after May 15, 2023: | |
| Medi-Cal Rates file -- Updated 5/15/2023 | |
| For services rendered on or after June 15, 2023: | |
| Medi-Cal Rates file -- Updated 6/15/2023 | |
| For services rendered on or after July 15, 2023: | |
| Medi-Cal Rates file -- Updated 7/15/2023 | |
| For services rendered on or after August 15, 2023: | |
| Medi-Cal Rates file -- Updated 8/15/2023 | |
| For services rendered on or after September 15, 2023: | |
| Medi-Cal Rates file -- Updated 9/15/2023 | |
| For services rendered on or after October 15, 2023: | |
| Medi-Cal Rates file -- Updated 10/15/2023 | |
| For services rendered on or after November 15, 2023: | |
| Medi-Cal Rates file -- Updated 11/15/2023 | |
| For services rendered on or after December 15, 2023: | |
| Medi-Cal Rates file -- Updated 12/15/2023 | |
| For services rendered on or after January 16, 2024: | |
| Medi-Cal Rates file -- Updated 1/16/2024 | |
| The Medi-Cal Rates file can be accessed each month on the Medi-Cal Rates home page. Excerpts of the Medi-Cal Rates files are posted on the DWC website: https://www.dir.ca.gov/dwc/FeeSchedules/Physician/Medi-Cal.asp | |
| National Correct Coding Initiative (NCCI) Edits: | For services rendered on or after February 15, 2023: |
| Medically Unlikely Edits | "Practitioner Services MUE Table (ZIP) -- Effective Jan. 1, 2023; Posted Dec. 1, 2022," in the document "MCR_MUE_PractitionerServices_Eff_02-15-2023", excluding all codes listed with Practitioner Services MUE Value of "0" (zero) |
| For services rendered on or after July 1, 2023: | |
| "Practitioner Services MUE Table (ZIP) -- Effective July 1, 2023; Posted June. 1, 2023," in the document "MCR_MUE_PractitionerServices_Eff_07-01-2023", excluding all codes listed with Practitioner Services MUE Value of "0" (zero) | |
| For services rendered on or after October 1, 2023: | |
| "Practitioner Services MUE Table (ZIP) -- Effective October 1, 2023; Posted September 1, 2023," in the document "MCR_MUE_PractitionerServices_Eff_10-01-2023", 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#7 | |
| National Correct Coding Initiative (NCCI) Edits: | For services on or after February 15, 2023: |
| National Correct Coding Initiative Policy Manual for Medicare Services | NCCI Policy Manual for Medicare (ZIP) -- Effective January 1, 2023, posted December 1, 2022 |
| Access on the CMS NCCI Policy Manual webpage | |
| National Correct Coding Initiative (NCCI) Edits: | For services rendered on or after February 15, 2023: |
| Practitioner Procedure to Procedure (PTP) Edits | Practitioner PTP Edits v290r1 (661,878 Records) 0001A/0591T -- 25999/96523 (ZIP) -- Effective Jan. 1, 2023; Posted Dec. 5, 2022 |
| Practitioner PTP Edits v290r1 (614,255 Records) 26010/01810 -- 36909/J2001 (ZIP) -- Effective Jan. 1, 2023; Posted Dec. 5, 2022 | |
| Practitioner PTP Edits v290r1 (595,695 Records) 37140/0213T -- 60699/96523 (ZIP) -- Effective Jan. 1, 2023; Posted Dec. 5, 2022 | |
| Practitioner PTP Edits v290r1 (669,559 Records) 61000/0213T -- U0003/U0004 (ZIP) -- Effective Jan. 1, 2023; Posted Dec. 5, 2022 | |
| For services rendered on or after July 1, 2023: | |
| Practitioner PTP Edits v292r0 (662,411 Records) 0001A/0591T -- 25999/96523 (ZIP) -- Effective July 1, 2023; Posted Jun. 1, 2023 | |
| Practitioner PTP Edits v292r0 (614,258 Records) 26010/01810 -- 36909/J2001 (ZIP) -- Effective July 1, 2023; Posted Jun. 1, 2023 | |
| Practitioner PTP Edits v292r0 (595,707 Records) 37140/0213T -- 60699/96523 (ZIP) -- Effective July 1, 2023; Posted Jun. 1, 2023 | |
| Practitioner PTP Edits v292r0 (669,603 Records) 61000/0213T -- U0003/U0004 (ZIP) -- Effective July 1, 2023; Posted Jun. 1, 2023 | |
| For services rendered on or after October 1, 2023: | |
| Practitioner PTP Edits v293r1 (662,411 Records) 0001A/0591T -- 25999/96523 (ZIP) -- Effective October 1, 2023; Posted September 14, 2023 | |
| Practitioner PTP Edits v293r1 (614,258 Records) 26010/01810 -- 36909/J2001 (ZIP) -- Effective October 1, 2023; Posted September 14, 2023 | |
| Practitioner PTP Edits v293r1 (595,709 Records) 37140/0213T -- 60699/96523 (ZIP) -- Effective October 1, 2023; Posted September 14, 2023 | |
| Practitioner PTP Edits v293r1 (669,619 Records) 61000/0213T -- U0003/U0004 (ZIP) -- Effective October 1, 2023; Posted September 14, 2023 | |
| Access the Practitioner PTP Edits on the CMS website: https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-procedure-procedure-ptp-edits | |
| 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 on the CMS website covers all time periods. | |
| Ophthalmology Procedure CPT codes subject to the MPPR | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP), PPRRVU23_JAN, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Ophthalmology Services Subject to MPPR. | |
| For services rendered on or after April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP), PPRRVU23_APR, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Ophthalmology Services Subject to MPPR. | |
| For services rendered on or after July 1, 2023: | |
| RVU23C (ZIP), PPRRVU23_JUL, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Ophthalmology Services Subject to MPPR. | |
| For services rendered on or after October 1, 2023: | |
| RVU23D (ZIP), PPRRVU23_OCT, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Diagnostic Ophthalmology Services Subject to MPPR. | |
| Physical Therapy Multiple Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after February 15, 2023: |
| RVU23A -- Updated 01/18/23 (ZIP), PPRRVU23_JAN, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-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 April 1, 2023: | |
| RVU23B -- Updated 02/27/23 (ZIP), PPRRVU23_APR, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-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, 2023: | |
| RVU23C (ZIP), PPRRVU23_JUL, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-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, 2023: | |
| RVU23D (ZIP), PPRRVU23_OCT, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2023 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1770-F_Separately Payable Therapy Services Subject to MPPR. | |
| In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
| Physician Time | CY 2023 PFS Final Rule Physician Work Time (Zip) |
| Splints and Casting Supplies | The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. |
| Telehealth -- Services Accessible Through Telehealth (using audio and video telecommunication method and audio only telecommunication method) During the COVID-19 Public Health Emergency | For services rendered on or after February 15, 2023: |
| List of Telehealth Services for Calendar Year 2023 (ZIP) -- Updated 11/02/2022 in the document "CMS-1770-F_CY2023_Final List of Medicare Telehealth Services" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. | |
| In accord with CPT 2023, append modifier 95 to procedure code when delivered via telehealth. | |
| For services rendered on or after April 1, 2023: | |
| List of Telehealth Services for Calendar Year 2023 (ZIP) -- Updated 02/13/2023 in the document "List of Telehealth Services for Calendar Year 2023 Updated 13Feb2023" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. | |
| In accord with CPT 2023, append modifier 95 to procedure code when delivered via telehealth. | |
| For services rendered on or after July 1, 2023: | |
| List of Telehealth Services for Calendar Year 2023 (ZIP) -- Updated 05/09/2023 in the document "List of Telehealth Services for Calendar Year 2023 Updated 09May2023" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. | |
| In accord with CPT 2023, append modifier 95 to procedure code when delivered via telehealth |
| Document/Data | Services Rendered On or After February 15, 2024 & Mid-year Updates |
| Adjustment Factors -- Services Other than Anesthesia | For all services other than anesthesia: |
| (These factors have been incorporated into the conversion factor listed below) | 2024 RVU budget neutrality adjustment factor: -2.18% (0.9782) |
| 2024 Annual increasein the MEI: 4.6% (1.046) | |
| Consolidated Appropriations Act, 2023, increase of 1.25% (1.0125) (effective from 2/15/2024 through 3/31/2024) | |
| Consolidated Appropriations Act, 2024, increase of 2.93% (1.0293) (effective April 1, 2024) | |
| Adjustment Factors -- Anesthesia | For anesthesia services: |
| (These factors have been incorporated into the conversion factors listed on section 9789.19.1 Table A Effective 2/15/2024) | 2024 RVU budget neutrality adjustment factor: -2.18% (0.9782) |
| 2024 Anesthesia practice expense and malpractice adjustment factor: 0.11% (1.0011) | |
| 2024 Annual increase in the MEI: 4.6% (1.046) | |
| Consolidated Appropriations Act, 2023, increase of 1.25% (1.0125) (effective from 2/15/2024 through 3/31/2024) | |
| Consolidated Appropriations Act, 2024, increase of 2.93% (1.0293) (effective April 1, 2024) | |
| Anesthesia Base Units by CPT Code | File name: CY 2022 Anesthesia Base Units 110921 |
| California-Specific Codes | WC001 -- Not reimbursable |
| WC002 -- $15.19 | |
| WC003 -- $47.04 for first page | |
| $28.92 each additional page. Maximum of six pages absent mutual agreement ($191.64) | |
| WC004 -- $47.04 for first page | |
| $28.92 each additional page. Maximum of seven pages absent mutual agreement ($220.56) | |
| WC005 -- $47.04 for first page | |
| $28.92 each additional page. Maximum of six pages absent mutual agreement ($191.64) | |
| WC007 -- $47.04 for first page | |
| $28.92 each additional page. Maximum of six pages absent mutual agreement ($191.64) | |
| WC008 -- $13.59 for up to the first 15 pages. $0.28 for each additional page after the first 15 pages. | |
| WC009 -- $13.59 for up to the first 15 pages. $0.28 for each additional page after the first 15 pages. | |
| WC010 -- $6.23 per x-ray | |
| WC011 -- $13.59 per scan | |
| WC012 -- No Fee Prescribed/Non Reimbursable absent agreement | |
| CMS' Medicare National Physician Fee Schedule Relative Value File [Zip] | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP) | |
| * RVU24A (Excluding Attachment A) | |
| * PPRRVU24_Jan | |
| * OPPSCAP_Jan | |
| * 24LOCCO | |
| * GPCI2024 | |
| Excluding: | |
| ANES2024 | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP) | |
| * RVU24B (Excluding Attachment A) | |
| * PPRRVU24_APR | |
| * OPPSCAP_APR | |
| * 24LOCCO | |
| * GPCI2024 | |
| Excluding: | |
| ANES2024 | |
| Access the Relative Value File on the CMS website: https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files | |
| Conversion Factor -- Anesthesia (before GPCI adjustment) | For services rendered on or after February 15, 2024 and on or before March 31, 2024: |
| Adjusted for MEI, Relative Value Scale adjustment factors, and application of Consolidated Appropriations Act, 2023, increase | Anesthesia Conversion Factor: $29.0948 |
| Adjusted for application of Consolidated Appropriations Act, 2024 increase | [See Section 9789.19.1 Table A Effective 2.15.2024 through 3.31.2024, effective for services on or after February 15, 2024 and on or before March 31, 2024, for GPCI-Adjusted Conversion Factors by locality] |
| For services rendered on or after April 1, 2024: | |
| Anesthesia Conversion Factor: $29.5775 | |
| [See Section 9789.19.1 Table A Effective 04.1.2024, effective for services on or after April 1, 2024, for GPCI-Adjusted Conversion Factors by locality] | |
| Conversion Factor -- Services Other than Anesthesia | For services rendered on or after February 15, 2024 and on or before March 31, 2024: |
| Adjusted for MEI, Relative Value Scale adjustment factor, and application of Consolidated Appropriations Act, 2023, increase | Other Services Conversion Factor: $47.72 |
| For services rendered on or after April 1, 2024: | |
| Other Services Conversion Factor: $48.51 | |
| Current Procedural Terminology (CPT®) | CPT 2024 |
| https://commerce.ama-assn.org/store/ | |
| Current Procedural Terminology CPT codes that shall not be used | Do not use CPT codes: |
| 27215 (Use G0412) | |
| 27216 (Use G0413) | |
| 27217 (Use G0414) | |
| 27218 (Use G0415) | |
| 76140 (see § 9789.17.2) | |
| 90889 (See § 9789.14. Use code WC005 code) | |
| 97014 (Use G0283) | |
| 99075 (see Medical-Legal fee schedule, § 9795) | |
| 99080 (see § 9789.14) | |
| 99242 through 99245 (see § 9789.12.12) | |
| 99252 through 99255 (see § 9789.12.12) | |
| 99417 (See § 9789.12.11. Use code G2212) | |
| 99455 and 99456 | |
| Diagnostic Cardiovascular Procedure CPT codes subject to the MPPR | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP), PPRRVU24_Jan, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP), PPRRVU24_Apr, number "6" in column S, labeled "Mult Proc" (Modifier 51), also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Cardiovascular Services Subject to MPPR | |
| Diagnostic Imaging Family Indicator Description | For services rendered on or after February 15, 2024: |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU24A -- Updated 01/03/2024 (ZIP), RVU24A (PDF document) | |
| For services rendered on or after April 1, 2024: | |
| Diagnostic Imaging Family Indicator: | |
| 88 = Subject to the reduction | |
| 99 = Concept does not apply | |
| RVU24B -- Updated 03/18/2024 (ZIP), RVU24B (PDF document) | |
| Diagnostic Imaging Family Procedures Subject to the MPPR | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP), PPRRVU24_Jan, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP), PPRRVU24_Apr, number "88" in column AB, labeled, "Diagnostic Imaging Family Indicator." Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Imaging Services Subject to MPPR. | |
| Diagnostic Imaging Multiple Procedures Subject to the MPPR | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP), PPRRVU24_Jan, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Imaging Services Subject to MPPR. | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP), PPRRVU24_Apr, number "4" in column S, labeled, "Mult Proc." Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Imaging Services Subject to MPPR. | |
| DWC Pharmaceutical Fee Schedule | Web address: |
| http://www.dir.ca.gov/dwc/OMFS9904.htm#8 | |
| Geographic Practice Cost Index (GPCI) by locality (Other than anesthesia services) | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP) | |
| * GPCI2024 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2024 PW GPCI (with 1.0 Floor)"), column F ("2024 PE GPCI"), and column G ("2024 MP GPCI") for the State of California | |
| * 24LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP) | |
| * GPCI2024 -- Column C ("Locality Number"), column D ("Locality Name"), column E ("2024 PW GPCI (with 1.0 Floor)"), column F ("2024 PE GPCI"), and column G ("2024 MP GPCI") for the State of California | |
| * 24LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California | |
| Access the Relative Value File (ZIP) on the CMS website: | |
| https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files Also, see Zip Code mapping files listed below. | |
| Geographic Practice Cost Index (GPCIs) by locality and anesthesia shares (Anesthesia) | For services rendered on or after February 15, 2024: |
| Section 9789.19.1 Table A Effective 2.15.2024 incorporates the Medicare locality GPCIs and anesthesia shares into updated locality-adjusted Anesthesia conversion factors. | |
| Locality determined by Medicare county to locality index. | |
| For services rendered on or after February 15, 2024: | |
| RVU24A -- Updated 01/03/2024 (ZIP) (County to locality index) | |
| * 24LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP) (County to locality index) | |
| * 24LOCCO -- Column B ("Locality Number"), column C ("State"), column D ("Fee Schedule Area"), and column E ("Counties") for the State of California ("CA") | |
| Also, see Zip Code mapping files listed below. | |
| Geographic Practice Cost Index (GPCI) locality mapping | For services rendered on or after February 15, 2024: |
| Zip Code files mapping zip codes to GPCI locality (for "other than anesthesia services" and anesthesia services) | "Zip Code to Carrier Locality File -- Revised 11/15/2023 (ZIP)", in the document "ZIP5_JAN24": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") |
| "Zip Codes requiring 4 extension -- Revised 11/15/2023 (ZIP)" in the document: "ZIP5_requiring +4ext_dec23_jan24", for the State of California ("CA") | |
| For services rendered on or after April 1, 2024: | |
| "Zip Code to Carrier Locality File -- Revised 2/15/2024 (ZIP)", in the document "ZIP5 APR2024": Column A ("STATE"), column B ("ZIP CODE"), and column D ("LOCALITY") for the State of California ("CA") | |
| "Zip Codes requiring 4 extension -- Revised 2/15/2024 (ZIP)" in the document: "ZIP5_requiring +4ext_apr24", for the State of California ("CA") | |
| Note: | |
| Access the Zip Code files on the CMS website: https://www.cms.gov/medicare/payment/fee-schedules | |
| Geographic Health Professional Shortage Area zip code data files | 2024 Primary Care HPSA (ZIP) |
| 2024 Mental Health HPSA (ZIP) | |
| Access the HPSA files on the CMS website: | |
| https://www.cms.gov/medicare/payment/fee-for-service-providers/physician-bonuses-health-professional-shortage-areas-hpsas | |
| Health Resources and Services Administration: Geographic HPSA shortage area query (By State & County) | Web address:https://data.hrsa.gov/tools/shortage-area/hpsa-find |
| Health Resources and Services Administration: Geographic HPSA shortage area query (By Address) | Web address:https://data.hrsa.gov/tools/medicare/physician-bonus |
| Incident To Codes | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP), PPRRVU24_JAN, number "5" in column N, labeled, "PCTC IND," (PC/TC Indicator) | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP), PPRRVU24_APR, 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 February 15, 2024: | |
| Medi-Cal Rates file -- Updated 2/15/2024 | |
| For services rendered on or after March 15, 2024: | |
| Medi-Cal Rates file -- Updated 3/15/2024 | |
| For services rendered on or after April 15, 2024: | |
| Medi-Cal Rates file -- Updated 4/15/2024 | |
| The Medi-Cal Rates file can be accessed each month on the Medi-Cal Rates home page. Excerpts of the Medi-Cal Rates files are posted on the DWC website: https://www.dir.ca.gov/dwc/FeeSchedules/Physician/Medi-Cal.asp | |
| National Correct Coding Initiative (NCCI) Edits: | For services rendered on or after February 15, 2024: |
| Medically Unlikely Edits | "Practitioner Services MUE Table (ZIP) -- Effective January 1, 2024; Posted Dec. 5, 2023", in the document "MCR_MUE_PractitionerServices_Eff_01-01-2024_R1", excluding all codes listed with Practitioner Services MUE Value of "0" (zero) |
| For services rendered on or after April 1, 2024: | |
| "Practitioner Services MUE Table (ZIP) -- Effective April 1, 2024; Posted March 1, 2024", in the document "MCR_MUE_PractitionerServices_Eff_04-01-2024", 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#7 | |
| National Correct Coding Initiative (NCCI) Edits: | For services on or after February 15, 2024: |
| National Correct Coding Initiative Policy Manual for Medicare Services | Medicare NCCI Policy Manual (ZIP) -- Effective January 1, 2024, posted December 1, 2023 |
| Access on the CMS NCCI Policy Manual webpage | |
| National Correct Coding Initiative (NCCI) Edits: | For services rendered on or after February 15, 2024: |
| Practitioner Procedure to Procedure (PTP) Edits | Practitioner PTP Edits v300r0 (636,288 Records) 0001A/0591T -- 25391/G0471 (ZIP) -- Effective Jan. 1, 2024; Posted Dec. 1, 2023 |
| Practitioner PTP Edits v300r0 (635,881 Records) 25392/01810 -- 36833/G0471 (ZIP) -- Effective Jan. 1, 2024; Posted Dec. 1, 2023 | |
| Practitioner PTP Edits v300r0 (635,917 Records) 36834/01844 -- 61592/G0471 (ZIP) -- Effective Jan. 1, 2024; Posted Dec. 1, 2023 | |
| Practitioner PTP Edits v300r0 (634,827 Records) 61595/0213T -- U0003/U0004 (ZIP) -- Effective Jan. 1, 2024; Posted Dec. 1, 2023 | |
| For services rendered on or after April 1, 2024: | |
| Practitioner PTP Edits v301r0 (645,065 Records) 0001A/0591T -- 25492/G0471 (ZIP) -- Effective Apr. 1, 2024; Posted Mar. 1, 2024 | |
| Practitioner PTP Edits v301r0 (645,145 Records) 25500/01810 -- 37221/J2001 (ZIP) -- Effective Apr. 1, 2024; Posted Mar. 1, 2024 | |
| Practitioner PTP Edits v301r0 (644,853 Records) 37222/11000 -- 62140/G0471 (ZIP) -- Effective Apr. 1, 2024; Posted Mar. 1, 2024 | |
| Practitioner PTP Edits v301r0 (610,026 Records) 62141/0213T -- U0003/U0004 (ZIP) -- Effective Apr. 1, 2024; Posted Mar. 1, 2024 | |
| Access the Practitioner PTP Edits on the CMS website: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits | |
| 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 on the CMS website covers all time periods. | |
| Ophthalmology Procedure CPT codes subject to the MPPR | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP), PPRRVU24_JAN, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| For services rendered on or after April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP), PPRRVU24_APR, number "7" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Diagnostic Ophthalmology Services Subject to MPPR | |
| Physical Therapy Multiple Procedure Payment Reduction: "Always Therapy" Codes; and Acupuncture and Chiropractic Codes | For services rendered on or after February 15, 2024: |
| RVU24A -- Updated 01/03/2024 (ZIP), PPRRVU24_JAN, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-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 April 1, 2024: | |
| RVU24B -- Updated 03/18/2024 (ZIP), PPRRVU24_APR, number "5" in column S, labeled "Mult Proc" (Modifier 51). Also listed in CY 2024 PFS Final Rule Multiple Procedure Payment Reduction Files (ZIP), in the document CMS-1784-F_Separately Payable Therapy Services Subject to MPPR. | |
| In addition, CPT codes: 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943 | |
| Physician Time | CY 2024 PFS Final Rule Physician Work Time -- Updated 12/19/2023 (ZIP) |
| Splints and Casting Supplies | The OMFS Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service. |
| Telehealth -- Services Accessible Through Telehealth (using audio and video telecommunication method and audio only telecommunication method) | For services rendered on or after February 15, 2024: |
| List of Telehealth Services for Calendar Year 2024 (ZIP) -- Updated 11/13/2023 in the document "CY 2024 PFS Final Rule List of Medicare Telehealth Services_V13Nov2023" | |
| File specifies codes that may be billed when service is rendered using audio only telecommunication and codes that may only be billed if service is rendered using a telecommunication method that includes both audio and video. | |
| See section 9789.12.2, subdivision (d) for Place of Service Codes. | |
| In accord with CPT 2024, append modifier 95 to procedure code when delivered via telehealth. |
Cal. Code Regs. Tit. 8, § 9789.19
Note: Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
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).
13. Amendment of subsections (a)-(f) and new subsections (g)-(k) filed 6/10/2024: operative 4-15-2024. Submitted to OAL as a file and print only pursuant to Labor Code section 5307.1(g)(2) (Register 2024, No. 24).