Pursuant to Labor Code section 5307.1, subdivision (g)(2), the Administrative Director of the Division of Workers’ Compensation ordered that the Durable Medical Equipment, Prosthetics, Orthotics, Supplies portion of the Official Medical Fee Schedule contained in title 8, California Code of Regulations, section 9789.60, is adjusted to conform to changes to the Medicare payment system that were adopted by the Centers for Medicare & Medicaid Services (CMS) in the October 2019 Quarter 4 DMEPOS Fee Schedule update.

Effective for services rendered on or after October 1, 2019, the maximum reasonable fees for Durable Medical Equipment, Prosthetics, Orthotics, Supplies shall not exceed 120% of the applicable California fees set forth in the Medicare calendar year 2019 “Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule” revised effective October 2019, contained in the electronic file “DME19-D [ZIP, 4MB]” which is adopted and incorporated by reference, excluding the “Former CBA Fee Schedule File”, “Former CBA National Mail-Order DTS Fee Schedule File”, and “Former CBA Zip Code File”.

The fee schedule data file (DMEPOS_OCT) sets forth two columns for California labelled: “CA (NR)” [California Non-Rural] and “CA (R)” [California Rural]. For the services on or after October 1, 2019, payment shall not exceed 120% of the fee set forth for the HCPCS code in the CA (NR) column, except the fee shall not exceed 120% of the fee set forth in the CA (R) column if the injured worker’s residence zip code appears on the DMERuralzip_Q42019 file. Where column CA (NR) sets forth a fee for a code, but CA (R) for the code is listed as “0.00” the fee shall not exceed 120% of the CA (NR) fee, regardless of whether the injured worker’s address zip code is rural or non-rural.

DME19-D [ZIP, 4MB] includes the following documents which are incorporated by reference:

— DMEBACK 2019
— DMEPOS_OCT
— DMEREAD 2019 rev 6-1-19
— DMERuralzip_Q42019

Excluding:
— Former CBA Fee Schedule File
— Former CBA National Mail-Order DTS Fee Schedule File
— Former CBA Zip Code File

The CMS Manual System, Pub 100-4 Medicare Claims Processing, Transmittal 4386, Change Request 11433, August 30, 2019 sets forth the fourth quarter changes and is relied upon in adopting this update Order.

CMS has not made second, third or fourth quarter updates to the 2019 Parenteral and Enteral Nutrition fee schedule (PEN) file. Therefore, the Administrative Director Order dated December 21, 2018 continues to be effective for Parenteral and Enteral Nutrition fees, and the DMEPEN_JAN file contained in the DME19-A remains effective for services rendered on or after October 1, 2019.

The Medicare October 2019 fourth quarter DMEPOS fee schedule revision is available on the Centers for Medicare & Medicaid Services’ DMEPOS Fee Schedule quarterly file webpage .