Cal. Code Regs. tit. 8 § 9789.12.2
Current through Register 2024 Notice Reg. No. 25, June 21, 2024
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:
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.
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.
| POS Code and Name | Payment Rate |
| Description | Facility = F |
| 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, and prior to March 1, 2020. For services on or after March 1, 2020, and prior to February 15, 2024, report the POS code that would have been reported had the service been furnished in person.) | |
| 02 Telehealth Provided Other than in Patient's Home | F |
| The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology. | |
| (Effective for services rendered on or after February 15, 2024.) | |
| 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. | |
| 10 Telehealth Provided in Patient's Home | NF |
| The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology. | |
| (Effective for services rendered on or after February 15, 2024.) | |
| 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. |
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.
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.
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.
Cal. Code Regs. Tit. 8, § 9789.12.2
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 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).
9. Amendment of subsection (d)(2) 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).