Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director - Administrative Rules
Article 5.3. Official Medical Fee Schedule

§9789.12.2. Calculation of the Maximum Reasonable Fee - Services Other than Anesthesia.

Except for fees determined pursuant to §9789.18.1 et seq., (Anesthesia), the base maximum reasonable fee for physician and non-physician professional medical practitioner services shall be the non-facility or facility fee calculated as follows:

(a) Non-facility site of service fee calculation:

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

[(Work RVU * Statewide Work GAF) + (Non-Facility PE RVU * Statewide PE GAF) + (MP RVU * Statewide MP GAF)] * Conversion Factor (CF) = Base Maximum Fee

Key:	RVU = Relative Value Unit
	GAF = Average Statewide Geographic Adjustment Factor
	Work = Physician Work
	PE = Practice Expense
	MP = Malpractice Expense

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

[(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor (CF) = Base Maximum Fee

Key:	RVU = Relative Value Unit
	GPCI = Geographic Practice Cost Index (by locality corresponding to the county where service was provided)
	Work = Physician Work
	PE = Practice Expense
	MP = Malpractice Expense

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

(b) Facility site of service fee calculation:

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

[(Work RVU * Statewide Work GAF) + (Facility PE RVU * Statewide PE GAF) + (MP RVU * Statewide MP GAF)] * Conversion Factor = Base Maximum Fee

Key:	RVU = Relative Value Unit
	GAF = Average Statewide Geographic Adjustment Factor
	Work = Physician Work
	PE = Practice Expense
	MP = Malpractice Expense

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

[(Work RVU * Work GPCI) + (Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor (CF) = Base Maximum Fee

Key:	RVU = Relative Value Unit
	GPCI = Geographic Practice Cost Index (by locality corresponding to the county where service was provided)
	Work = Physician Work
	PE = Practice Expense
	MP = Malpractice Expense

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

(c) “Facility RVUs” shall be used where the place of service is listed as facility (“F”) in subdivision (d). “Non-Facility Total RVUs” shall be used where the place of service is listed as nonfacility (“NF”) in subdivision (d).

(d)(1) The place of service code (POS) is used to identify where the procedure is furnished. All services shall be assigned the POS code for the setting in which the patient received the face-to-face service. In cases where the face-to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the POS code assigned by the physician/practitioner shall be the setting in which the patient received the Technical Component (TC) of the service.

(2) This face-to-face rule does not apply where the patient is receiving care as a registered inpatient or an outpatient of a hospital. The correct POS code assignment will be for the setting in which the patient is receiving inpatient care or outpatient care from a hospital, including the inpatient hospital (POS code 21) or the outpatient hospital (POS 19 or POS 22).

	Payment Rate
POS Code and Name	Facility = F
Description	Nonfacility = NF
01 Pharmacy	NF
A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients.
02 Telehealth	F
The location where health services and health related services are provided or received, through a telecommunication system. (Effective for services on or after March 1, 2017)
03 School	NF
A facility whose primary purpose is education.
04 Homeless Shelter	NF
A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency
shelters, individual or family shelters).
09 Prison/Correctional Facility	NF
A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State
or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.
11 Office	NF
Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State
or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health
examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
12 Home or Private Residence of Patient	NF
Location, other than a hospital or other facility, where the patient receives care in a private residence.
13 Assisted Living Facility	NF
Congregate residential facility with self-contained living units providing assessment of each resident's needs and on-site
support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and
other services.
14 Group Home	NF
A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral
services, custodial service, and minimal services (e.g., medication administration).
15 Mobile Unit	NF
A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment
services.
16 Temporary Lodging	NF
A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care,
and which is not identified by any other POS code.
17 Walk-in Retail Health Clinic	NF
A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by
any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive
and primary care services.
18 Place of Employment/Worksite	NF
A location, not described by any other POS code, owned or operated by a public or private entity where the patient is
employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or
rehabilitative services to the individual.
19 Off Campus-Outpatient Hospital	F
A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and
nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
(Effective for Services on or after January 1, 2016)
20 Urgent Care Facility	NF
Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness
or injury for unscheduled, ambulatory patients seeking immediate medical attention.
21 Inpatient Hospital	F
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and
rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
22 Outpatient Hospital	F
A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services
to sick or injured persons who do not require hospitalization or institutionalization. (Effective for Services prior to
January 1, 2016)
22 On Campus-Outpatient Hospital	F
A portion of a hospital's main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and
rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Effective
for Services on or after January 1, 2016)
23 Emergency Room-Hospital	F
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
24 Ambulatory Surgical Center	F
A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an
ambulatory basis.
31 Skilled Nursing Facility	F
A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical,
nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
32 Nursing Facility	NF
A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured,
disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than
mentally retarded individuals.
33 Custodial Care Facility	NF
A facility which provides room, board and other personal assistance services, generally on a longterm basis, and which
does not include a medical component.
34 Hospice - for inpatient care	F
A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their
families are provided.
41 Ambulance-Land	F
A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
42 Ambulance-Air or Water	F
An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
49 Independent Clinic	NF
A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to
provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.
51 Inpatient Psychiatric Facility	F
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis,
by or under the supervision of a physician.
52 Psychiatric Facility-Partial Hospitalization	F
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who
do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a
hospital-based or hospital-affiliated facility.
53 Community Mental Health Center	F
A facility that provides the following services: outpatient services, including specialized outpatient services for children,
the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been
discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment,
other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for
admission to State mental health facilities to determine the appropriateness of such admission; and consultation and
education services.
54 Intermediate Care Facility/Mentally Retarded	NF
A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded
individuals but does not provide the level of care or treatment available in a hospital or skilled nursing facility (SNF).
55 Residential Substance Abuse Treatment Facility	NF
A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute
medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs
and supplies, psychological testing, and room and board.
56 Psychiatric Residential Treatment Center	F
A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and
professionally staffed group living and learning environment.
57 Non-residential Substance Abuse Treatment Facility	NF
A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include
individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological
testing.
60 Mass Immunization Center	NF
A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these
services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass
immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.
61 Comprehensive Inpatient Rehabilitation Facility	F
A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with
physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological
services, and orthotics and prosthetics services.
62 Comprehensive Outpatient Rehabilitation Facility	NF
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with
physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
65 End-Stage Renal Disease Treatment Facility	NF
A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on
an ambulatory or home-care basis.
71 State or Local Public Health Clinic	NF
A facility maintained by either State or local health departments that provides ambulatory primary medical care under
the general direction of a physician.
72 Rural Health Clinic	NF
A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care
under the general direction of a physician.
81 Independent Laboratory	NF
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.
99 Other Place of Service	NF
Other place of service not identified above.

(e)(1) For dates of service on or after January 1, 2014, but before January 1, 2019, see section 9789.19, by date of service, for the average statewide GAFs.

(2) For dates of service on or after January 1, 2019, see section 9789.19, by date of service, for reference to the Geographic Practice Code Index (GPCI) values by payment locality.

(A) Determination of Payment Locality: The payment locality is based upon the county in which the service was provided, determined by the ZIP code of the location where the service is actually performed and not necessarily the physical locality of the provider's office, except as otherwise specified in subdivisions (e)(2)(B) and (e)(2)(C).

(i) For purposes of determining the appropriate payment locality, the name and address, including the ZIP code, for each service code must be included on the bill, in accordance with the medical treatment billing regulations at 9792.5.0 et seq.

(ii) See section 9789.19, by date of service, for reference to: counties included in locality file; the zip code to payment locality file; and the zip codes requiring +4 extension file. For zip codes that span more than one county, the 9-digit zip code is required to map to the payment locality.

(B) Determination of Payment Locality for Radiology Services, Pathology Services, and Other Diagnostic Procedures:

(i) Global Service Code - If the global diagnostic code (no modifier TC and no modifier -26) is billed, the provider must report the name and address, including the ZIP code, of where the test was furnished on the bill for the global diagnostic service code. For example, when the global diagnostic service code is billed for chest x-ray as described by CPT code 71045 (no modifier TC and no modifier -26), the locality is determined by the ZIP code applicable to the testing facility.

In order to bill for a global diagnostic service code, the same physician or supplier entity must furnish both the TC and the PC of the diagnostic service and the TC and PC must be furnished within the same payment locality.

(ii) Separate Billing of Professional Interpretation:

If the physician or supplier entity does not furnish both the TC and PC of the diagnostic service, or if the physician or supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different payment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician. The interpreting physician must report the name and address, including ZIP code, of the location where professional interpretation was furnished on the bill. If the professional interpretation was furnished at an unusual and infrequent location, for example, a hotel, the locality of the professional interpretation is determined based on where the interpreting physician most commonly practices.

(C) Global Surgical Package - Determination of Payment Locality When Services are Provided in Different Payment Localities:

If portions of the global period are provided in different payment localities, the physician must report the name and address, including ZIP code, of the location where the service was rendered. The procedure code for the surgery is billed with modifier -54; and the postoperative care is billed with the procedure code for the surgery with modifier -55. For example, if the surgery is performed in one GPCI locality and the postoperative care is provided in another GPCI locality, the surgery is billed with modifier “- 54” and the payment locality would be where the surgery was performed. The postoperative care is billed with modifier “-55” and the payment locality would be where the postoperative care was performed. This is true whether the services were performed by the same physician/group or different physicians/groups. See sections 9789.16.2, et seq. for additional billing requirements for global surgeries.

(f) The maximum fee for physician and non-physician practitioner services shall be the lesser of the actual charge or the calculated rate established by this fee schedule.

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

HISTORY

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).

2. Amendment of subsection (b) 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. Amendment of subsection (d)(2) 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).

4. Editorial correction of subsection (d)(2) (Register 2017, No. 5).

5. Editorial correction of subsection (d)(2) (Register 2017, No. 14).

6. Editorial correction of subsection (d)(2) (Register 2017, No. 19).

7. Amendment of subsection (d)(2) 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).

8. Amendment of subsections (a)-(b), redesignation and amendment of former subsection (e) as new subsection (e)(1) and new subsections (e)(2)-(e)(2)(C) 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).