Fee Schedules, Billing Codes, and Payment Rules
Fee schedule basics
California uses the Official Medical Fee Schedule (OMFS) for medical services, the Medical-Legal Fee Schedule for evaluator reports, and the Pharmacy Fee Schedule. Billing codes include CPT, HCPCS, ICD-10, and ML codes. Payment rules cover RBRVS conversion factors, by-report versus per-page billing, and duplicate or unbundled charges.
Traps
Questions often test whether a service is billed by report or by CPT code, and whether a modifier changes payment. Another trap is confusing medical-legal fees with treatment fees, or applying the wrong conversion factor. Watch for lien filing deadlines and fee schedule updates.
Rule of thumb
When a code is not listed in the fee schedule, it is generally billed by report with documentation. Worked example: a QME report billed under ML-201 uses the per-report fee, not an hourly rate; if the report exceeds a page threshold, additional per-page fees may apply.
Key concepts
Know OMFS, RBRVS, CPT/HCPCS, ML codes, by-report billing, and lien deadlines.
Permanent Disability Evaluation and Rating
PD framework
Permanent disability is rated using the AMA Guides and the PDRS (Permanent Disability Rating Schedule). Key concepts include whole person impairment, apportionment under sections 4663 and 4664, the 15% increase for the first 70% of PD, and life pension for high ratings. The P&S (permanent and stationary) report triggers PD evaluation.
Traps
Questions often confuse apportionment (causation-based) with disability percentage, or misapply the 15% adjustment. Another trap is mixing PDRS editions or failing to account for occupational versus non-occupational factors. Watch for life pension thresholds and PD rate maximums.
Rule of thumb
Apply the 15% increase only to the first 70% of PD. Worked example: a 50% PD rating is increased by 15% on the first 70%, producing an adjusted rating; amounts above 70% are not increased. Always confirm the PDRS edition in effect at the date of injury.
Key concepts
Know P&S, PDRS, AMA Guides, apportionment, life pension, and the 15% adjustment.