Cal. Code Regs. tit. 22 § 51503 : Social Security — Health Care Services — California Medical Assistance Program — Health Care Services — Payment for Services and Supplies — Physician Services

(a) Except as otherwise provided, reimbursement for physician services shall be the usual charges made to the general public not to exceed the maximum reimbursement rates listed in this section for each procedure performed by a physician.

(b) Except as set forth in (d), (e), (h), (k) and (l), the maximum reimbursement rates for physician services shall be the rates set forth in the "Schedule of Medi-Cal Physician Rates", published by the Department of Health Services, June 2002, herein incorporated by reference in its entirety.

(c) As used in (b), a given procedure listed in the "Schedule of Medi-Cal Physician Rates" means those procedures which are a benefit of the Medi-Cal program as determined by the Department.

(d) The maximum reimbursement for "By Report" procedures, and procedures not listed in the "Schedule of Medi-Cal Physician Rates" shall be based upon a review of such procedures to determine their relationship to other procedures for which reimbursement rates are established.

(e) The maximum reimbursement rate for professional services for immunizations shall be $9.00. The maximum reimbursement rate for professional services for other injections shall be $4.46.

(f) Maximum reimbursement rates for anesthesia services shall be determined in accordance with this Section, except anesthesia services performed by a nurse anesthetist and billed by a physician shall be reimbursed in accordance with Section 51505.2. Physicians billing for anesthesia services performed by a nurse anesthetist shall indicate on the claim that such services were performed by a nurse anesthetist.

(g) Reimbursement for services rendered on or after November 1, 1976 by physicians which were provided in hospital outpatient emergency, examining, and treatment rooms shall be reduced to 80 percent of the maximum reimbursement rates as set forth in (b) unless:

(1) The physician is called from outside the outpatient department setting to provide emergency services.

(2) The physician or group of physicians contract with a hospital and assume total financial responsibility for such outpatient services.

(3) Specified medical procedures, as determined by the Department, when performed in a hospital outpatient setting may be reimbursed at the rates set forth in (b).

(h) Pathology tests that are not listed in (b) shall be reimbursed in accordance with the provisions of section 51529.

(i) In compliance with section 51501 and notwithstanding any provision of Title XVIII of the Social Security Act, Medi-Cal payments for a physician's services to outpatient dialysis patients shall be made only to providers of service.

(j)The Medi-Cal program, through its intermediary, will pay allowable Medi-Cal rates for direct patient care services in a teaching setting when directly provided by teaching physicians only when such services are provided and billed in accordance with program policies and regulations of the Department of Health Services and when:

(1) They are performed for necessary treatment of the patient;

(2) They are not an exercise of teaching supervision without direct patient care services being provided;

(3) They do not duplicate any medical services billed by any other provider; and

(4) The teaching physician is not on salary or contract to the hospital for the direct patient care services provided.

No professional fees are payable for services provided independently by residents or students in a teaching setting.

(k) Reimbursement for an early discharge follow up visit provided to a mother and her newborn shall be made when the conditions specified in Section 51327(b) are met. Each early discharge follow up visit shall be separately reimbursed when the physician providing service to the mother is different from the physician providing service to the newborn. Services provided to the mother and her newborn shall be billed using Evaluation and Management Code 99499 with the modifier "ZW."

(l) Physician services provided under the California Children's Services program shall be reimbursed at rates which are 39.7 percent greater than the Medi-Cal rate which would otherwise be applicable.

Cal. Code Regs. Tit. 22, § 51503

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14077, 14105, 14132.42 and 14148.4, Welfare and Institutions Code; Statutes of 1982, Chapter 1594, Section 77; Statutes of 1983, Chapter 323, Section 149; Statutes of 1984, Chapter 268, Section 66; Statutes of 1986, Chapter 186, Items 4260-106-001 and 890; Statutes of 1992, Chapter 722, Section 88, Statutes of 1998, Chapter 324, Items 4260-101-0001 and 0890; Statutes of 1999, Chapter 50, Items 4260-101-0001 and 4260-101-0890; Section 433.123, Title 42, Code of Federal Regulations; and Statutes of 2000, Chapter 52, Items 4260-101-0001 and 0890.

1. Amendment of subsection (b), relettering of former subsections (f)-(k) to subsections (g)-(l) and new subsection (f) filed 1-19-90 as an emergency; operative 1-19-90 (Register 90, No. 5). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed by operation of law on 5-21-90. For prior history, see Register 89, No. 21.
2. Certificate of Compliance as to 1-19-90 order including amendment of subsection (f) transmitted to OAL 5-18-90 and filed 6-15-90 (Register 90, No. 32).
3. Amendment of subsections (a), table in subsection (b), subsection (h) and Note filed 10-1-92 with Secretary of State by Department of Health Services; operative 10-1-92. Submitted to OAL for printing only pursuant to section 147(c), SB 485, (Chapter 722, Statutes of 1992) (Register 92, No. 40).
4. Certificate of Compliance as to 10-1-92 order transmitted to OAL 1-2-93 and filed 3-12-93 (Register 93, No. 11).
5. Amendment of subsection (g) and Note filed 4-11-96 as an emergency pursuant to section 14105 of the Welfare and Institutions Code; operative 1-18-96 pursuant to Stats. 1995, ch. 303 item 4260-101-001, sec. 5 (Register 96, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-9-96 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 4-11-96 order transmitted to OAL 8-7-96 and filed 9-13-96 (Register 96, No. 37).
7. Repealer of subsection (h), new subsections (h)-(h)(3), and amendment of Note filed 12-30-97; operative 5-1-98 (Register 98, No. 1).
8. Amendment of subsections (b), (f) and (g) and amendment of Note filed 3-1-99 as an emergency; operative 3-1-99 (Register 99, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-29-99 or emergency language will be repealed by operation of law on the following day.
9. Reinstatement of section as it existed prior to 3-1-99 emergency amendment by operation of Government Code section 11346.1(f) (Register 99, No. 33).
10. Amendment of subsections (b), (f) and (g) and amendment of Note filed 8-10-99 as an emergency; operative 8-10-99 (Register 99, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-8-99 or emergency language will be repealed by operation of law on the following day.
11. Certificate of Compliance as to 8-10-99 order transmitted to OAL 12-2-99 and filed 1-13-2000 (Register 2000, No. 2).
12. New subsection (m) and amendment of Note filed 3-13-2000 as an emergency; operative 3-13-2000 (Register 2000, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-11-2000 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 3-13-2000 order transmitted to OAL 7-5-2000 and filed 8-14-2000 (Register 2000, No. 33).
14. Amendment of subsections (b), (f) and (h)(2), new subsection (n) and amendment of Note filed 11-13-2000 as an emergency; operative 11-13-2000 (Register 2000, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-13-2001 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 11-13-2000 order transmitted to OAL 3-13-2001 and filed 4-4-2001 (Register 2001, No. 14).
16. Amendment of section and Note filed 7-16-2002; operative rates for services provided on or after 8-1-2000 pursuant to Stats. 2000, c. 52 Items 4260-101-0001 and 0890 (Register 2002, No. 29).
17. Certificate of Compliance as to 7-16-2002 order, including repealer of subsection (m), transmitted to OAL 11-12-2002 and filed 12-24-2002 (Register 2002, No. 52).