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The Division of Workers’ Compensation (DWC) has issued a notice of public hearing to revise Title 8 CCR section 9789.32 of the hospital outpatient departments and ambulatory surgical centers (HOPD/ASC) fee schedule. The public hearing has been scheduled for 10 a.m., June 17, in the Auditorium of the Elihu Harris Building, 1515 Clay Street in Oakland. Members of the public may also submit written comment on the regulation until 5 p.m. that day.

This rulemaking action to amend the OMFS HOPD/ASC fee schedule is necessary to make more specific the payment method for “Other Services”. Because Medicare occasionally changes its coding practices, it is necessary to provide guidance on the proper HCPCS code to use for calculating “Other Services” maximum payment amounts when a different HCPCS code is used to describe comparable Other Services under CMS’ Hospital Outpatient Departments Prospective Payment System (CMS HOPPS) and the OMFS RBRVS. Refining the payment methodology to include guidance on which HCPCS code to use is beneficial because payable outpatient services might otherwise be denied.

For example, effective January 1, 2014, CMS began to recognize HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient) and no longer recognizes CPT codes 99201-99205 (evaluation and management – new patient) and 99211-99215 (evaluation and management – established patient) for payment under the CMS HOPPS. The OMFS RBRVS, however, continues to recognize CPT codes 99201-99205 and 99211-99215, but does not recognize HCPCS code G0463. As a result, it has come to the Division’s attention that hospitals are being denied payment for these clinic visits. This amendment will specify that when this circumstance occurs, the clinic visit should be paid in accordance with the HCPCS code used under the OMFS RBRVS.

The notice and text of the regulation can be found on the proposed regulations page.