06/05/2015

CASA Comments on Proposed Workers' Compensation Changes

The California Division of Workers’ Compensation (DWC), is proposing to modify an existing regulation related to the HOPD/ASC fee schedule, by amending Article 5.3 of Chapter 4.5, Subchapter 1, Division 1, of Title 8, California Code of Regulations. The DWC has issued a notice of public hearing and comments regarding the revision. CASA has submitted formal comments to the DWC, in support of the proposed changes. CASA Comments 6.5.15

The proposed amendment to the HOPD/ASC fee schedule regulation provides guidance regarding which HCPCS code to use, when Medicare changes its coding practices resulting in different HCPCS codes to describe comparable “Other Services” under CMS’ Hospital Outpatient Departments Prospective Payment System and the OMFS physician fee schedule.

The DWC states, “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."

CASA provided comments on how California ASCs have also been affected by recent Medicare changes to HCPCS codes and have incurred denied payment for their services. For example, ASCs performing a sacroiliac joint injection utilizing fluoroscopic guidance have been instructed by Medicare to use HCPCS code G0260. ASCs are now seeing denial of these services as workers’ compensation carriers are stating that these codes are not part of the OMFS HOPD/ASC schedule. By establishing guidance and including these codes, it should lead to diminished confusion, less administrative time on the part of the payor and the provider, and improved access, outcomes and satisfaction for the injured worker.

In addition, CASA requested that the DWC amend the regulations to adopt the same Hospital Outpatient PPS geographic-adjusted conversion factor utilized by Medicare. Our research shows that the actual maximum facility fee for an ASC is less than the 80 percent of the Medicare HOPD as proscribed by statute and regulation. The DWC uses a different geographic wage adjustment methodology from Medicare, as well as a different conversion factor for determining the ultimate HOPD fee schedule.  The difference in the conversion factor is approximately 2.78 percent.

The DWC is holding a public hearing on June 17, 2015, at 10 a.m., in the Auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland, CA 94612. Members of the public may also submit written comment on the regulation until 5 p.m. that day. Further information can be found at the following link DWC Proposed Regs.