This section describes the maximum reimbursement rates for physicians, podiatrists, nurse anesthetists, physician groups and hospital outpatient departments. For additional information about room charges for facilities, refer to Rates: Maximum Reimbursement for Outpatient Room Rates, in the appropriate Part 2
Reimbursement Calculation Effective August 1, 2000, Medi-Cal’s physician fee schedule is no
for Physician Services longer based upon the 1969 California Relative Value Studies
(CRVS). Medi-Cal assigns its own unit values for all physician services, except pathology (which generally uses 1974 CRVS values or Medicare’s Maximum Allowance), and anesthesia (which uses 90.3 percent of the Uniform Relative Value Guide values).
To determine the basic reimbursement rate for a service, multiply the assigned unit value by the conversion factor on the following pages. Anesthesia reimbursement is calculated differently as noted in the following sections. The Medi-Cal Web site has the unit value for each procedure. It also provides the actual dollar figure resulting from this computation. The Web site location is www.medi-cal.ca.gov.
“By Report” and unlisted procedures are priced individually based on information included on or with the claim form.
Anesthesia: Physician The maximum reimbursement rates allowed for anesthesiologist services (CPT-4 codes 00100 – 01999) are derived by adding the base unit (for the procedure code) plus the time units (15 minutes per unit) and multiplying by a conversion factor. An additional time unit may be billed only if the fractional time equals or exceeds five minutes, or if total anesthesia time is less than five minutes (California Code of Regulations [CCR], Title 22, Section 51505.2). See the Anesthesia section in this manual for additional billing instructions.
Anesthesia: Certified The maximum reimbursement rates allowed for Certified Registered
Registered Nurse Nurse Anesthetist...