CCLME.ORG - DIVISION 1. DEPARTMENT OF INDUSTRIAL RELATIONS CHAPTERS 1 through 6

(continued)
93 INTERSTITIAL LUNG DISEASE 0.7309 1.000 0.7309 3.3
W/O CC
94 PNEUMOTHORAX W CC 1.1704 1.000 1.1704 4.8
95 PNEUMOTHORAX W/O CC 0.6098 1.000 0.6098 3
96 BRONCHITIS & ASTHMA AGE 0.7871 1.000 0.7871 3.9
>17 W CC
97 BRONCHITIS & ASTHMA AGE 0.5873 1.000 0.5873 3.1
>17 W/O CC
98 BRONCHITIS & ASTHMA AGE 0.8768 1.000 0.8768 3.2
0-17
99 RESPIRATORY SIGNS & 0.7117 1.000 0.7117 2.5
SYMPTOMS W CC
100 RESPIRATORY SIGNS & 0.5437 1.000 0.5437 1.8
SYMPTOMS W/O CC
101 OTHER RESPIRATORY SYSTEM
DIAGNOSES
W CC 0.8563 1.000 0.8563 3.3
102 OTHER RESPIRATORY SYSTEM
DIAGNOSES
W/O CC 0.555 1.000 0.5550 2.1
103 HEART TRANSPLANT exclu- excluded excluded excluded
ded
104 CARDIAC VALVE PROCEDURES W
CARDIAC
CATH 7.1843 1.000 7.1843 8.9
105 CARDIAC VALVE PROCEDURES
W/O CARDIAC
CATH 5.6567 1.000 5.6567 7.4
106 CORONARY BYPASS W CARDIAC 7.5203 1.000 7.5203 9.3
CATH
107 CORONARY BYPASS W/O 5.3762 1.000 5.3762 9.2
CARDIAC CATH
108 OTHER CARDIOTHORACIC 5.6525 1.000 5.6525 8
PROCEDURES
109 CORONARY BYPASS W/O PTCA
OR CARDIAC
CATH 4.0198 1.000 4.0198 6.8
110 MAJOR CARDIOVASCULAR
PROCEDURES
W CC 4.1358 1.000 4.1358 7.1
111 MAJOR CARDIOVASCULAR
PROCEDURES
W/O CC 2.241 1.000 2.2410 4.7
112 PERCUTANEOUS
CARDIOVASCULAR
PROCEDURES 1.8677 0.841 1.5705 2.6
113 AMPUTATION FOR CIRC SYSTEM
DISORDERS
EXCEPT UPPER LIMB & TOE 2.7806 1.000 2.7806 9.8
114 UPPER LIMB & TOE
AMPUTATION FOR CIRC
SYSTEM DISORDERS 1.5656 1.000 1.5656 6
115 PERM PACE IMPLNT W AMI,HRT
FAIL OR SHOCK
OR AICD LEAD OR GEN PROC 3.4711 1.000 3.4711 6
116 OTH PERM CARDIAC PACEMAKER
IMPLANT OR
PTCA W CORONARY ART STENT 2.419 1.000 2.4190 2.6
117 CARDIAC PACEMAKER REVISION
EXCEPT
DEVICE REPLACEMENT 1.2966 1.000 1.2966 2.6
118 CARDIAC PACEMAKER DEVICE 1.4939 1.000 1.4939 1.9
REPLACEMENT
119 VEIN LIGATION & STRIPPING 1.26 1.000 1.2600 2.9
120 OTHER CIRCULATORY SYSTEM
O.R.
PROCEDURES 2.0352 1.000 2.0352 4.9
121 CIRCULATORY DISORDERS W
AMI & MAJOR
COMP DISCH ALIVE 1.6194 1.000 1.6194 5.5
122 CIRCULATORY DISORDERS W
AMI W/O MAJOR
COMP DISCH ALIVE 1.0884 1.000 1.0884 3.3
123 CIRCULATORY DISORDERS W 1.5528 1.000 1.5528 2.8
AMI, EXPIRED
124 CIRCULATORY DISORDERS
EXCEPT AMI, W
CARD CATH & COMPLEX DIAG 1.4134 1.000 1.4134 3.3
125 CIRCULATORY DISORDERS
EXCEPT AMI, W CARD
CATH W/O COMPLEX DIAG 1.0606 1.000 1.0606 2.2
126 ACUTE & SUBACUTE 2.5379 1.000 2.5379 9.3
ENDOCARDITIS
127 HEART FAILURE & SHOCK 1.013 1.000 1.0130 4.2
128 DEEP VEIN THROMBOPHLEBITIS 0.7651 1.000 0.7651 5
129 CARDIAC ARREST, 1.0968 1.000 1.0968 1.8
UNEXPLAINED
130 PERIPHERAL VASCULAR 0.9471 1.000 0.9471 4.7
DISORDERS W CC
131 PERIPHERAL VASCULAR 0.5898 1.000 0.5898 3.6
DISORDERS W/O CC
132 ATHEROSCLEROSIS W CC 0.6707 1.000 0.6707 2.4
133 ATHEROSCLEROSIS W/O CC 0.5663 1.000 0.5663 1.9
134 HYPERTENSION 0.5917 1.000 0.5917 2.6
135 CARDIAC CONGENITAL &
VALVULAR
DISORDERS AGE >17 W CC 0.9083 1.000 0.9083 3.3
136 CARDIAC CONGENITAL &
VALVULAR
DISORDERS AGE >17 W/O CC 0.6065 1.000 0.6065 2.2
137 CARDIAC CONGENITAL &
VALVULAR
DISORDERS AGE 0-17 0.8192 1.000 0.8192 3.3
138 CARDIAC ARRHYTHMIA &
CONDUCTION
DISORDERS W CC 0.8291 1.000 0.8291 3.1
139 CARDIAC ARRHYTHMIA &
CONDUCTION
DISORDERS W/O CC 0.5141 1.000 0.5141 2
140 ANGINA PECTORIS 0.574 0.783 0.4497 2.2
141 SYNCOPE & COLLAPSE W CC 0.7219 1.000 0.7219 2.9
142 SYNCOPE & COLLAPSE W/O CC 0.5552 1.000 0.5552 2.2
143 CHEST PAIN 0.5402 0.842 0.4547 1.8
144 OTHER CIRCULATORY SYSTEM
DIAGNOSES
W CC 1.1668 1.000 1.1668 3.8
145 OTHER CIRCULATORY SYSTEM
DIAGNOSES
W/O CC 0.6322 1.000 0.6322 2.2
146 RECTAL RESECTION W CC 2.743 1.000 2.7430 8.9
147 RECTAL RESECTION W/O CC 1.6221 1.000 1.6221 6
148 MAJOR SMALL & LARGE BOWEL
PROCEDURES
W CC 3.4347 1.000 3.4347 10.1
149 MAJOR SMALL & LARGE BOWEL
PROCEDURES
W/O CC 1.5667 1.000 1.5667 6.1
150 PERITONEAL ADHESIOLYSIS W 2.8523 1.000 2.8523 9.1
CC
151 PERITONEAL ADHESIOLYSIS 1.3427 1.000 1.3427 4.8
W/O CC
152 MINOR SMALL & LARGE BOWEL
PROCEDURES
W CC 1.9462 1.000 1.9462 6.8
153 MINOR SMALL & LARGE BOWEL
PROCEDURES
W/O CC 1.208 1.000 1.2080 4.9
154 STOMACH, ESOPHAGEAL &
DUODENAL
PROCEDURES AGE >17 W CC 4.1475 1.000 4.1475 10.1
155 STOMACH, ESOPHAGEAL &
DUODENAL
PROCEDURES AGE >17 W/O CC 1.3751 1.000 1.3751 3.3
156 STOMACH, ESOPHAGEAL &
DUODENAL
PROCEDURES AGE 0-17 0.8436 1.000 0.8436 6
157 ANAL & STOMAL PROCEDURES W 1.2388 1.000 1.2388 3.9
CC
158 ANAL & STOMAL PROCEDURES 0.6638 1.000 0.6638 2.1
W/O CC
159 HERNIA PROCEDURES EXCEPT
INGUINAL &
FEMORAL AGE >17 W CC 1.3347 1.000 1.3347 3.8
160 HERNIA PROCEDURES EXCEPT
INGUINAL &
FEMORAL AGE >17 W/O CC 0.7837 0.902 0.7066 2.2
161 INGUINAL & FEMORAL HERNIA
PROCEDURES
AGE >17 W CC 1.1017 1.000 1.1017 2.9
162 INGUINAL & FEMORAL HERNIA
PROCEDURES
AGE >17 W/O CC 0.6229 0.867 0.5402 1.6
163 HERNIA PROCEDURES AGE 0-17 0.6921 1.000 0.6921 2.4
164 APPENDECTOMY W COMPLICATED
PRINCIPAL
DIAG W CC 2.376 1.000 2.3760 7.1
165 APPENDECTOMY W COMPLICATED
PRINCIPAL
DIAG W/O CC 1.2838 1.000 1.2838 4.3
166 APPENDECTOMY W/O
COMPLICATED PRINCIPAL
DIAG W CC 1.4802 1.000 1.4802 4
167 APPENDECTOMY W/O
COMPLICATED PRINCIPAL
DIAG W/O CC 0.8937 1.000 0.8937 2.3
168 MOUTH PROCEDURES W CC 1.2141 1.000 1.2141 3.2
169 MOUTH PROCEDURES W/O CC 0.7455 1.000 0.7455 1.9
170 OTHER DIGESTIVE SYSTEM
O.R. PROCEDURES
W CC 2.8686 1.000 2.8686 7.7
171 OTHER DIGESTIVE SYSTEM
O.R. PROCEDURES
W/O CC 1.1975 1.000 1.1975 3.6
172 DIGESTIVE MALIGNANCY W CC 1.3485 1.000 1.3485 5.1
173 DIGESTIVE MALIGNANCY W/O 0.77 1.000 0.7700 2.8
CC
174 G.I. HEMORRHAGE W CC 0.9985 1.000 0.9985 3.9
175 G.I. HEMORRHAGE W/O CC 0.5501 1.000 0.5501 2.5
176 COMPLICATED PEPTIC ULCER 1.1052 1.000 1.1052 4.1
177 UNCOMPLICATED PEPTIC ULCER 0.8998 1.000 0.8998 3.7
W CC
178 UNCOMPLICATED PEPTIC ULCER 0.6604 1.000 0.6604 2.6
W/O CC
179 INFLAMMATORY BOWEL DISEASE 1.0576 1.000 1.0576 4.7
180 G.I. OBSTRUCTION W CC 0.9423 1.000 0.9423 4.2
181 G.I. OBSTRUCTION W/O CC 0.5304 1.000 0.5304 2.8
182 ESOPHAGITIS, GASTROENT &
MISC DIGEST
DISORDERS AGE >17 W CC 0.7922 1.000 0.7922 3.4
183 ESOPHAGITIS, GASTROENT &
MISC DIGEST
DISORDERS AGE >17 W/O CC 0.5717 1.000 0.5717 2.4
184 ESOPHAGITIS, GASTROENT &
MISC DIGEST
DISORDERS AGE 0-17 0.5119 1.000 0.5119 2.5
185 DENTAL & ORAL DIS EXCEPT
EXTRACTIONS
& RESTORATIONS, AGE >17 0.8621 1.000 0.8621 3.3
186 DENTAL & ORAL DIS EXCEPT
EXTRACTIONS &
RESTORATIONS, AGE 0-17 0.3216 1.000 0.3216 2.9
187 DENTAL EXTRACTIONS & 0.7649 1.000 0.7649 2.9
RESTORATIONS
188 OTHER DIGESTIVE SYSTEM
DIAGNOSES AGE >17
W CC 1.1005 1.000 1.1005 4.1
189 OTHER DIGESTIVE SYSTEM
DIAGNOSES AGE >17
W/O CC 0.5796 1.000 0.5796 2.4
190 OTHER DIGESTIVE SYSTEM
DIAGNOSES
AGE 0-17 0.9884 1.000 0.9884 4.1
191 PANCREAS, LIVER & SHUNT 4.3914 1.000 4.3914 10.5
PROCEDURES W CC
192 PANCREAS, LIVER & SHUNT
PROCEDURES
W/O CC 1.7916 1.000 1.7916 5.3
193 BILIARY TRACT PROC EXCEPT
ONLY CHOLECYST
W OR W/O C.D.E. W CC 3.3861 1.000 3.3861 10.3
194 BILIARY TRACT PROC EXCEPT
ONLY CHOLECYST
W OR W/O C.D.E. W/O CC 1.6191 1.000 1.6191 5.6
195 CHOLECYSTECTOMY W C.D.E. W 2.9062 1.000 2.9062 8.3
CC
196 CHOLECYSTECTOMY W C.D.E. 1.6593 1.000 1.6593 4.9
W/O CC
197 CHOLECYSTECTOMY EXCEPT BY
LAPAROSCOPE
W/O C.D.E. W CC 2.4544 1.000 2.4544 7.2
198 CHOLECYSTECTOMY EXCEPT BY
LAPAROSCOPE
W/O C.D.E. W/O CC 1.2339 1.000 1.2339 3.9
199 HEPATOBILIARY DIAGNOSTIC
PROCEDURE FOR
MALIGNANCY 2.3584 1.000 2.3584 7.2
200 HEPATOBILIARY DIAGNOSTIC
PROCEDURE FOR
NON-MALIGNANCY 3.2262 1.000 3.2262 7
201 OTHER HEPATOBILIARY OR
PANCREAS O.R.
PROCEDURES 3.4035 1.000 3.4035 10.2
202 CIRRHOSIS & ALCOHOLIC 1.3001 1.000 1.3001 4.9
HEPATITIS
203 MALIGNANCY OF
HEPATOBILIARY SYSTEM OR
PANCREAS 1.325 1.000 1.3250 5
204 DISORDERS OF PANCREAS
EXCEPT
MALIGNANCY 1.2018 1.000 1.2018 4.5
205 DISORDERS OF LIVER EXCEPT
MALIG,CIRR,ALC
HEPA W CC 1.2048 1.000 1.2048 4.7
206 DISORDERS OF LIVER EXCEPT
MALIG,CIRR,ALC
HEPA W/O CC 0.6751 1.000 0.6751 3
207 DISORDERS OF THE BILIARY 1.1032 1.000 1.1032 4
TRACT W CC
208 DISORDERS OF THE BILIARY 0.6538 1.000 0.6538 2.3
TRACT W/O CC
209 MAJOR JOINT & LIMB
REATTACHMENT
PROCEDURES OF LOWER 2.0912 0.950 1.9866 4.6
EXTREMITY
210 HIP & FEMUR PROCEDURES
EXCEPT MAJOR
JOINT AGE >17 W CC 1.8152 1.180 2.1419 6
211 HIP & FEMUR PROCEDURES
EXCEPT MAJOR
JOINT AGE >17 W/O CC 1.2647 0.973 1.2300 4.5
212 HIP & FEMUR PROCEDURES
EXCEPT MAJOR
JOINT AGE 0-17 0.8472 1.000 0.8472 11.1
213 AMPUTATION FOR
MUSCULOSKELETAL SYSTEM
& CONN TISSUE DISORDERS 1.7726 1.000 1.7726 6.4
214 NO LONGER VALID 0 0.967 0.0000 0
215 NO LONGER VALID 0 0.956 0.0000 0
216 BIOPSIES OF
MUSCULOSKELETAL SYSTEM
& CONNECTIVE TISSUE 2.2042 1.000 2.2042 7.1
217 WND DEBRID & SKN GRFT
EXCEPT HAND,
FOR MUSCSKELET & CONN TISS 2.923 0.572 1.6711 8.9
DIS
218 LOWER EXTREM & HUMER PROC
EXCEPT HIP,
FOOT,FEMUR AGE >17 W CC 1.5337 1.030 1.5794 4.2
219 LOWER EXTREM & HUMER PROC
EXCEPT HIP,
FOOT,FEMUR AGE >17 W/O CC 1.0255 0.968 0.9928 2.7
220 LOWER EXTREM & HUMER PROC
EXCEPT HIP,
FOOT,FEMUR AGE 0-17 0.5844 1.000 0.5844 5.3
221 NO LONGER VALID 0 0.818 0.0000 0
222 NO LONGER VALID 0 1.038 0.0000 0
223 MAJOR SHOULDER/ELBOW PROC,
OR OTHER
UPPER EXTREMITY PROC W CC 0.9585 0.885 0.8483 2
224 SHOULDER,ELBOW OR FOREARM
PROC,EXC
MAJOR JOINT PROC, W/O CC 0.7997 1.012 0.8095 1.7
225 FOOT PROCEDURES 1.0851 1.001 1.0860 3.3
226 SOFT TISSUE PROCEDURES W 1.477 1.000 1.4770 4.3
CC
227 SOFT TISSUE PROCEDURES W/O 0.8036 0.944 0.7588 2.1
CC
228 MAJOR THUMB OR JOINT
PROC,OR OTH HAND
OR WRIST PROC W CC 1.0664 0.906 0.9665 2.4
229 HAND OR WRIST PROC, EXCEPT
MAJOR JOINT
PROC, W/O CC 0.7169 1.037 0.7432 1.8
230 LOCAL EXCISION & REMOVAL
OF INT FIX
DEVICES OF HIP & FEMUR 1.249 1.000 1.2490 3.4
231 LOCAL EXCISION & REMOVAL
OF INT FIX
DEVICES EXCEPT HIP & FEMUR 1.3825 0.734 1.0149 3.2
232 ARTHROSCOPY 1.0828 0.817 0.8842 2.3
233 OTHER MUSCULOSKELET SYS &
CONN TISS O.R.
PROC W CC 2.089 1.000 2.0890 5.3
234 OTHER MUSCULOSKELET SYS &
CONN TISS O.R.
PROC W/O CC 1.2661 0.813 1.0297 2.7
235 FRACTURES OF FEMUR 0.7582 1.000 0.7582 3.8
236 FRACTURES OF HIP & PELVIS 0.7218 0.979 0.7066 4
237 SPRAINS, STRAINS, &
DISLOCATIONS OF HIP,
PELVIS & THIGH 0.5681 1.000 0.5681 3
238 OSTEOMYELITIS 1.3496 1.000 1.3496 6.4
239 PATHOLOGICAL FRACTURES &
MUSCULOSKELETAL & CONN
TISS
MALIGNANCY 0.9745 1.000 0.9745 4.9
240 CONNECTIVE TISSUE 1.2712 1.000 1.2712 4.9
DISORDERS W CC
241 CONNECTIVE TISSUE 0.6177 1.000 0.6177 3.1
DISORDERS W/O CC
242 SEPTIC ARTHRITIS 1.0724 1.000 1.0724 5.1
243 MEDICAL BACK PROBLEMS 0.7262 0.761 0.5526 3.7
244 BONE DISEASES & SPECIFIC
ARTHROPATHIES
W CC 0.7155 1.000 0.7155 3.7
245 BONE DISEASES & SPECIFIC
ARTHROPATHIES
W/O CC 0.4832 1.000 0.4832 2.8
246 NON-SPECIFIC ARTHROPATHIES 0.557 1.000 0.5570 2.9
247 SIGNS & SYMPTOMS OF
MUSCULOSKELETAL
SYSTEM & CONN TISSUE 0.5696 1.000 0.5696 2.6
248 TENDONITIS, MYOSITIS & 0.7864 1.000 0.7864 3.7
BURSITIS
249 AFTERCARE, MUSCULOSKELETAL
SYSTEM &
CONNECTIVE TISSUE 0.6913 1.000 0.6913 2.6
250 FX, SPRN, STRN & DISL OF
FOREARM, HAND,
FOOT AGE >17 W CC 0.6929 1.000 0.6929 3.3
251 FX, SPRN, STRN & DISL OF
FOREARM, HAND,
FOOT AGE >17 W/O CC 0.4995 0.901 0.4501 2.4
252 FX, SPRN, STRN & DISL OF
FOREARM, HAND,
FOOT AGE 0-17 0.2538 1.000 0.2538 1.8
253 FX, SPRN, STRN & DISL OF
UPARM,LOWLEG
EX FOOT AGE >17 W CC 0.7253 1.000 0.7253 3.7
254 FX, SPRN, STRN & DISL OF
UPARM,LOWLEG
EX FOOT AGE >17 W/O CC 0.4413 1.003 0.4427 2.6
255 FX, SPRN, STRN & DISL OF
UPARM,LOWLEG
EX FOOT AGE 0-17 0.2956 1.000 0.2956 2.9
256 OTHER MUSCULOSKELETAL
SYSTEM &
CONNECTIVE TISSUE 0.7959 1.000 0.7959 3.8
DIAGNOSES
257 TOTAL MASTECTOMY FOR
MALIGNANCY
W CC 0.9107 1.000 0.9107 2.3
258 TOTAL MASTECTOMY FOR
MALIGNANCY
W/O CC 0.7232 1.000 0.7232 1.8
259 SUBTOTAL MASTECTOMY FOR
MALIGNANCY
W CC 0.9068 1.000 0.9068 1.8
260 SUBTOTAL MASTECTOMY FOR
MALIGNANCY
W/O CC 0.6532 1.000 0.6532 1.3
261 BREAST PROC FOR
NON-MALIGNANCY EXCEPT
BIOPSY & LOCAL EXCISION 0.9362 1.000 0.9362 1.7
262 BREAST BIOPSY & LOCAL
EXCISION FOR
NON-MALIGNANCY 0.8754 1.000 0.8754 2.7
263 SKIN GRAFT &/OR DEBRID FOR
SKN ULCER OR
CELLULITIS W CC 2.1219 1.000 2.1219 8.9
264 SKIN GRAFT &/OR DEBRID FOR
SKN ULCER OR
CELLULITIS W/O CC 1.1479 1.000 1.1479 5.4
265 SKIN GRAFT &/OR DEBRID
EXCEPT FOR SKIN
ULCER OR CELLULITIS W CC 1.5309 1.000 1.5309 4.3
266 SKIN GRAFT &/OR DEBRID
EXCEPT FOR SKIN
ULCER OR CELLULITIS W/O CC 0.8707 1.131 0.9844 2.4
267 PERIANAL & PILONIDAL 1.0792 1.000 1.0792 3.1
PROCEDURES
268 SKIN, SUBCUTANEOUS TISSUE
& BREAST
PLASTIC PROCEDURES 1.1405 1.000 1.1405 2.4
269 OTHER SKIN, SUBCUT TISS &
BREAST PROC
W CC 1.7004 1.000 1.7004 5.8
270 OTHER SKIN, SUBCUT TISS &
BREAST PROC
W/O CC 0.767 1.000 0.7670 2.3
271 SKIN ULCERS 1.0104 1.000 1.0104 5.5
272 MAJOR SKIN DISORDERS W CC 0.9994 1.000 0.9994 4.8
273 MAJOR SKIN DISORDERS W/O 0.6179 1.000 0.6179 3.2
CC
274 MALIGNANT BREAST DISORDERS 1.2061 1.000 1.2061 4.9
W CC
275 MALIGNANT BREAST DISORDERS 0.5301 1.000 0.5301 2.4
W/O CC
276 NON-MALIGANT BREAST 0.6899 1.000 0.6899 3.6
DISORDERS
277 CELLULITIS AGE >17 W CC 0.8396 0.791 0.6641 4.7
278 CELLULITIS AGE >17 W/O CC 0.5522 0.865 0.4779 3.6
279 CELLULITIS AGE 0-17 0.6644 1.000 0.6644 4.2
280 TRAUMA TO THE SKIN, SUBCUT
TISS &
BREAST AGE >17 W CC 0.6788 1.000 0.6788 3.2
281 TRAUMA TO THE SKIN, SUBCUT
TISS &
BREAST AGE >17 W/O CC 0.4729 0.971 0.4591 2.4
282 TRAUMA TO THE SKIN, SUBCUT
TISS &
BREAST AGE 0-17 0.257 1.000 0.2570 2.2
283 MINOR SKIN DISORDERS W CC 0.6917 1.000 0.6917 3.5
284 MINOR SKIN DISORDERS W/O 0.4336 1.000 0.4336 2.5
CC
285 AMPUTAT OF LOWER LIMB FOR
ENDOCRINE,
NUTRIT,& METABOL DISORDERS 1.9961 1.000 1.9961 7.7
286 ADRENAL & PITUITARY 2.1299 1.000 2.1299 4.9
PROCEDURES
287 SKIN GRAFTS & WOUND DEBRID
FOR ENDOC,
NUTRIT & METAB DISORDERS 1.8283 1.000 1.8283 7.8
288 O.R. PROCEDURES FOR 2.1607 1.000 2.1607 4.5
OBESITY
289 PARATHYROID PROCEDURES 0.9914 1.000 0.9914 2
290 THYROID PROCEDURES 0.9193 1.000 0.9193 1.8
291 THYROGLOSSAL PROCEDURES 0.5487 1.000 0.5487 1.4
292 OTHER ENDOCRINE, NUTRIT &
METAB O.R.
PROC W CC 2.4538 1.000 2.4538 6.9
293 OTHER ENDOCRINE, NUTRIT &
METAB O.R.
PROC W/O CC 1.2289 1.000 1.2289 3.6
294 DIABETES AGE >35 0.7589 1.000 0.7589 3.6
295 DIABETES AGE 0-35 0.7587 1.000 0.7587 2.9
296 NUTRITIONAL & MISC
METABOLIC DISORDERS
AGE >17 W CC 0.8594 1.000 0.8594 4
297 NUTRITIONAL & MISC
METABOLIC DISORDERS
AGE >17 W/O CC 0.5179 1.000 0.5179 2.8
298 NUTRITIONAL & MISC
METABOLIC DISORDERS
AGE 0-17 0.5269 1.000 0.5269 2.5
299 INBORN ERRORS OF 0.9632 1.000 0.9632 4
METABOLISM
300 ENDOCRINE DISORDERS W CC 1.0829 1.000 1.0829 4.7
301 ENDOCRINE DISORDERS W/O CC 0.6133 1.000 0.6133 2.9
302 KIDNEY TRANSPLANT exclu- excluded excluded excluded
ded
303 KIDNEY,URETER & MAJOR
BLADDER
PROCEDURES FOR NEOPLASM 2.4602 1.000 2.4602 7
304 KIDNEY,URETER & MAJOR
BLADDER PROC FOR
NON-NEOPL W CC 2.3407 1.000 2.3407 6.4
305 KIDNEY,URETER & MAJOR
BLADDER PROC FOR
NON-NEOPL W/O CC 1.1825 1.000 1.1825 3.1
306 PROSTATECTOMY W CC 1.2489 1.000 1.2489 3.7
307 PROSTATECTOMY W/O CC 0.646 1.000 0.6460 1.9
308 MINOR BLADDER PROCEDURES W 1.6449 1.000 1.6449 4.2
CC
309 MINOR BLADDER PROCEDURES 0.9339 1.000 0.9339 2
W/O CC
310 TRANSURETHRAL PROCEDURES W 1.1172 1.000 1.1172 3
CC
311 TRANSURETHRAL PROCEDURES 0.6174 1.000 0.6174 1.6
W/O CC
312 URETHRAL PROCEDURES, AGE 1.0173 1.000 1.0173 3
>17 W CC
313 URETHRAL PROCEDURES, AGE 0.6444 1.000 0.6444 1.7
>17 W/O CC
314 URETHRAL PROCEDURES, AGE 0.4953 1.000 0.4953 2.3
0-17
315 OTHER KIDNEY & URINARY
TRACT O.R.
PROCEDURES 2.0474 1.000 2.0474 4.2
316 RENAL FAILURE 1.3424 1.000 1.3424 4.9
317 ADMIT FOR RENAL DIALYSIS 0.7395 1.000 0.7395 2.1
318 KIDNEY & URINARY TRACT 1.1313 1.000 1.1313 4.3
NEOPLASMS W CC
319 KIDNEY & URINARY TRACT
NEOPLASMS
W/O CC 0.604 1.000 0.6040 2.2
320 KIDNEY & URINARY TRACT
INFECTIONS
AGE >17 W CC 0.8621 1.000 0.8621 4.3
321 KIDNEY & URINARY TRACT
INFECTIONS
AGE >17 W/O CC 0.5686 1.000 0.5686 3.2
322 KIDNEY & URINARY TRACT
INFECTIONS
AGE 0-17 0.4939 1.000 0.4939 3.3
323 URINARY STONES W CC, &/OR
ESW
LITHOTRIPSY 0.7996 1.000 0.7996 2.4
324 URINARY STONES W/O CC 0.4509 1.000 0.4509 1.6
325 KIDNEY & URINARY TRACT
SIGNS & SYMPTOMS
AGE >17 W CC 0.646 1.000 0.6460 3
326 KIDNEY & URINARY TRACT
SIGNS & SYMPTOMS
AGE >17 W/O CC 0.4297 1.000 0.4297 2.1
327 KIDNEY & URINARY TRACT
SIGNS & SYMPTOMS
AGE 0-17 0.3543 1.000 0.3543 3.1
328 URETHRAL STRICTURE AGE >17 0.7455 1.000 0.7455 2.8
W CC
329 URETHRAL STRICTURE AGE >17 0.5253 1.000 0.5253 1.7
W/O CC
330 URETHRAL STRICTURE AGE 0.3191 1.000 0.3191 1.6
0-17
331 OTHER KIDNEY & URINARY
TRACT
DIAGNOSES AGE >17 W CC 1.0221 1.000 1.0221 4.1
332 OTHER KIDNEY & URINARY
TRACT
DIAGNOSES AGE >17 W/O CC 0.5997 1.000 0.5997 2.5
333 OTHER KIDNEY & URINARY
TRACT
DIAGNOSES AGE 0-17 0.8247 1.000 0.8247 3.5
334 MAJOR MALE PELVIC 1.5591 1.000 1.5591 4.2
PROCEDURES W CC
335 MAJOR MALE PELVIC 1.1697 1.000 1.1697 3.2
PROCEDURES W/O CC
336 TRANSURETHRAL 0.888 1.000 0.8880 2.7
PROSTATECTOMY W CC
337 TRANSURETHRAL 0.6152 1.000 0.6152 1.9
PROSTATECTOMY W/O CC
338 TESTES PROCEDURES, FOR 1.19 1.000 1.1900 3.5
MALIGNANCY
339 TESTES PROCEDURES,
NON-MALIGNANCY
AGE >17 1.0769 1.000 1.0769 3
340 TESTES PROCEDURES,
NON-MALIGNANCY
AGE 0-17 0.2835 1.000 0.2835 2.4
341 PENIS PROCEDURES 1.1709 1.000 1.1709 2.1
342 CIRCUMCISION AGE >17 0.824 1.000 0.8240 2.5
343 CIRCUMCISION AGE 0-17 0.1541 1.000 0.1541 1.7
344 OTHER MALE REPRODUCTIVE
SYSTEM O.R.
PROCEDURES FOR MALIGNANCY 1.1519 1.000 1.1519 1.6
345 OTHER MALE REPRODUCTIVE
SYSTEM O.R.
PROC EXCEPT FOR MALIGNANCY 0.88 1.000 0.8800 2.6
346 MALIGNANCY, MALE
REPRODUCTIVE SYSTEM,
W CC 0.9756 1.000 0.9756 4.3
347 MALIGNANCY, MALE
REPRODUCTIVE SYSTEM,
W/O CC 0.5922 1.000 0.5922 2.4
348 BENIGN PROSTATIC 0.7142 1.000 0.7142 3.2
HYPERTROPHY W CC
349 BENIGN PROSTATIC 0.438 1.000 0.4380 2
HYPERTROPHY W/O CC
350 INFLAMMATION OF THE MALE
REPRODUCTIVE
SYSTEM 0.6992 1.000 0.6992 3.6
351 STERILIZATION, MALE 0.2364 1.000 0.2364 1.3
352 OTHER MALE REPRODUCTIVE
SYSTEM
DIAGNOSES 0.6858 1.000 0.6858 2.8
353 PELVIC EVISCERATION,
RADICAL HYSTERECTOMY
& RADICAL VULVECTOMY 1.9292 1.000 1.9292 5.3
354 UTERINE,ADNEXA PROC FOR
NON-OVARIAN/
ADNEXAL MALIG W CC 1.5284 1.000 1.5284 4.9
355 UTERINE,ADNEXA PROC FOR
NON-OVARIAN/
ADNEXAL MALIG W/O CC 0.9278 1.000 0.9278 3.1
356 FEMALE REPRODUCTIVE SYSTEM
RECONSTRUCTIVE PROCEDURES 0.7846 1.000 0.7846 2.1
357 UTERINE & ADNEXA PROC FOR
OVARIAN OR
ADNEXAL MALIGNANCY 2.3628 1.000 2.3628 6.9
358 UTERINE & ADNEXA PROC FOR
NON-MALIGNANCY W CC 1.2263 1.000 1.2263 3.7
359 UTERINE & ADNEXA PROC FOR
NON-MALIGNANCY W/O CC 0.8593 1.000 0.8593 2.6
360 VAGINA, CERVIX & VULVA 0.886 1.000 0.8860 2.4
PROCEDURES
361 LAPAROSCOPY & INCISIONAL
TUBAL
INTERRUPTION 1.2318 1.000 1.2318 2.2
362 ENDOSCOPIC TUBAL 0.3022 1.000 0.3022 1.4
INTERRUPTION
363 D&C, CONIZATION &
RADIO-IMPLANT, FOR
MALIGNANCY 0.8136 1.000 0.8136 2.5
364 D&C, CONIZATION EXCEPT FOR 0.753 1.000 0.7530 2.6
MALIGNANCY
365 OTHER FEMALE REPRODUCTIVE
SYSTEM O.R.
PROCEDURES 1.8425 1.000 1.8425 4.9
366 MALIGNANCY, FEMALE
REPRODUCTIVE
SYSTEM W CC 1.2467 1.000 1.2467 4.8
367 MALIGNANCY, FEMALE
REPRODUCTIVE
SYSTEM W/O CC 0.5676 1.000 0.5676 2.4
368 INFECTIONS, FEMALE 1.1205 1.000 1.1205 5
REPRODUCTIVE SYSTEM
369 MENSTRUAL & OTHER FEMALE
REPRODUCTIVE
SYSTEM DISORDERS 0.5704 1.000 0.5704 2.4
370 CESAREAN SECTION W CC 1.0631 1.000 1.0631 4.4
371 CESAREAN SECTION W/O CC 0.7157 1.000 0.7157 3.3
372 VAGINAL DELIVERY W
COMPLICATING
DIAGNOSES 0.6077 1.000 0.6077 2.7
373 VAGINAL DELIVERY W/O
COMPLICATING
DIAGNOSES 0.4169 1.000 0.4169 2
374 VAGINAL DELIVERY W
STERILIZATION &/OR
D&C 0.7565 1.000 0.7565 2.6
375 VAGINAL DELIVERY W O.R.
PROC EXCEPT
STERIL &/OR D&C 0.686 1.000 0.6860 4.4
376 POSTPARTUM & POST ABORTION
DIAGNOSES
W/O O.R. PROCEDURE 0.5224 1.000 0.5224 2.6
377 POSTPARTUM & POST ABORTION
DIAGNOSES
W O.R. PROCEDURE 0.8899 1.000 0.8899 2.6
378 ECTOPIC PREGNANCY 0.7664 1.000 0.7664 2
379 THREATENED ABORTION 0.3959 1.000 0.3959 2
380 ABORTION W/O D&C 0.4843 1.000 0.4843 1.8
381 ABORTION W D&C, ASPIRATION
CURETTAGE
OR HYSTEROTOMY 0.5331 1.000 0.5331 1.5
382 FALSE LABOR 0.2127 1.000 0.2127 1.3
383 OTHER ANTEPARTUM DIAGNOSES
W MEDICAL
COMPLICATIONS 0.5137 1.000 0.5137 2.7
384 OTHER ANTEPARTUM DIAGNOSES
W/O MEDICAL
COMPLICATIONS 0.3161 1.000 0.3161 1.6
385 NEONATES, DIED OR
TRANSFERRED TO
ANOTHER ACUTE CARE 1.3767 1.000 1.3767 1.8
FACILITY
386 EXTREME IMMATURITY OR
RESPIRATORY
DISTRESS SYNDROME, NEONATE 4.54 1.000 4.5400 17.9
387 PREMATURITY W MAJOR 3.1007 1.000 3.1007 13.3
PROBLEMS
388 PREMATURITY W/O MAJOR 1.8709 1.000 1.8709 8.6
PROBLEMS
389 FULL TERM NEONATE W MAJOR 1.8408 1.000 1.8408 4.7
PROBLEMS
390 NEONATE W OTHER 0.9471 1.000 0.9471 3
SIGNIFICANT PROBLEMS
391 NORMAL NEWBORN 0.1527 1.000 0.1527 3.1
392 SPLENECTOMY AGE >17 3.1739 1.000 3.1739 7.1
393 SPLENECTOMY AGE 0-17 1.3486 1.000 1.3486 9.1
394 OTHER O.R. PROCEDURES OF
THE BLOOD AND
BLOOD FORMING ORGANS 1.5969 1.000 1.5969 4.1
395 RED BLOOD CELL DISORDERS 0.8257 1.000 0.8257 3.3
AGE >17
396 RED BLOOD CELL DISORDERS 1.1573 1.000 1.1573 2.5
AGE 0-17
397 COAGULATION DISORDERS 1.2278 1.000 1.2278 3.8
398 RETICULOENDOTHELIAL &
IMMUNITY
DISORDERS W CC 1.275 1.000 1.2750 4.7
399 RETICULOENDOTHELIAL &
IMMUNITY
DISORDERS W/O CC 0.6881 1.000 0.6881 2.8
400 LYMPHOMA & LEUKEMIA W
MAJOR O.R.
PROCEDURE 2.6309 1.000 2.6309 5.8
401 LYMPHOMA & NON-ACUTE
LEUKEMIA W
OTHER O.R. PROC W CC 2.7198 1.000 2.7198 7.8
402 LYMPHOMA & NON-ACUTE
LEUKEMIA W
OTHER O.R. PROC W/O CC 1.0985 1.000 1.0985 2.8
403 LYMPHOMA & NON-ACUTE 1.7594 1.000 1.7594 5.7
LEUKEMIA W CC
404 LYMPHOMA & NON-ACUTE
LEUKEMIA
W/O CC 0.848 1.000 0.8480 3.1
405 ACUTE LEUKEMIA W/O MAJOR
O.R.
PROCEDURE AGE 0-17 1.912 1.000 1.9120 4.9
406 MYELOPROLIF DISORD OR
POORLY DIFF
NEOPL W MAJ O.R.PROC W CC 2.8275 1.000 2.8275 7.6
407 MYELOPROLIF DISORD OR
POORLY DIFF
NEOPL W MAJ O.R.PROC W/O 1.3179 1.000 1.3179 3.6
CC
408 MYELOPROLIF DISORD OR
POORLY DIFF
NEOPL W OTHER O.R.PROC 2.0008 1.000 2.0008 4.8
409 RADIOTHERAPY 1.1215 1.000 1.1215 4.4
410 CHEMOTHERAPY W/O ACUTE
LEUKEMIA AS
SECONDARY DIAGNOSIS 0.9468 1.000 0.9468 2.9
411

Appendix C. Ratios Applied to Revise Certain DRG Weights in California
Number DRG Ratio
004 Spinal Procs 0.6283
008 Peripheral/Cranial Nerve & Orth OR Nervous Sys. Procs 0.8082
025 Seizures and Headaches: AD WO CC 0.7485
029 Traumatic Stupor and Coma: AD WO CC 1.0025
032 Concussion: AD WO CC 0.8749
042 Intraocular Proc Exc. Retina, Iris and Lens 1.0661
063 Other Ear, Nose, Mouth and Throat OR Procs 0.8753
112 Percutaneous Cardiovascular Procs 0.8409
140 Angina Pectoris 0.7834
143 Chest Pain 0.8417
160 Hernia Proc: AD Exc. Inguinal or Femoral, WO CC 0.9016
162 Hernia Proc: AD Inguinal or Femoral, WO CC 0.8672
209 Major Joints and Limb Reattachment, Lower Extremity 0.9500
210 Hip and Femur, Exc Major joint Proc: AD W CC 1.1800
211 Hip and Femur, Exc Major joint Proc: AD WO CC 0.9726
214 Back and Neck Proc W CC 0.9674
215 Back and Neck Procs WO CC 0.9556
217 Wound Debridement and Skin Graft Exc. Hand 0.5717
218 Lower Extr/Humerous Exc. Hip, Foot and Femur:
AD W CC 1.0298
219 Lower Extr/Humer. Exc. Hip, Foot and Femur:
AD WO CC 0.9681
221 Knee Proc W CC 0.8177
222 Knee Proc WO CC 1.0382
223 Maj. Shoulder/Elbow Proc/Other Upper Extrem.
Proc W CC 0.8850
224 Shoulder/Elbow/Forearm Proc exc. Major Joint
Proc WO CC 1.0122
225 Foot Proc 1.0008
227 Soft Tissue Proc WO CC 0.9443
228 Major Thumb/Joint Proc, or Other Hand or Wrist
Proc W CC 0.9063
229 Hand and Wrist Proc, Exc. Major joint Proc WO CC 1.0367
231 Local Excision/Removal Int. Fix. Devices Exc.
Hip & Femur 0.7341
232 Arthroscopy 0.8166
234 Oth. Musculoskel. Sys/Connective Tissue OR Procs
WO CC 0.8133
236 Fracture of Hip and Pelvis 0.9790
243 Medical Back 0.7609
251 Frac, Sprain, Strain, Disloc Forearm, Hand/Foot:
AD WO CC 0.9012
254 Frac, Sprain, Strain, Disloc Up Arm/Low Leg ex Foot:
AD W CC 1.0031
266 Skin Graft/Debridement Exc. Skin Ulcer or Cellulitis
WO CC 1.1306
277 Cellulitis: AD W CC 0.7910
278 Cellulitis: AD WO CC 0.8654
281 Trauma to Skin, Subcutaneous Tiss and Breast:
AD WO CC 0.9709
415 Infectious and Parasitic Disease OR Proc 0.4907
418 Postoperative and Post traumatic Infection 0.6801
440 Wound Debridement for Injury 0.7738
441 Hand Proc for Injury 0.9914
443 Other Proc for Injury WO CC 1.0024
445 Traumatic Injury: AD WO CC 0.8112
450 Injury/Poison/Drug: AD WO CC 0.6657
455 Other Injury/Poisoning and Toxic Effect Diagnosis
WO CC 0.7483
461 OR Proc with Diagnosis of Other Contact with
Health Services 0.9207

s 9792.5. Payment for Medical Treatment.
(a) As used in this section:
(1) "Claims Administrator" has the same meaning specified in Section 9785(a)(3).
(2) "Medical treatment" means the treatment to which an employee is entitled under Labor Code Section 4600.

(3) "Physician" has the same meaning specified in Labor Code Section 3209.3.
(4) "Required report" means a report which must be submitted pursuant to Section 9785.
(5) "Treating physician" means the "primary treating physician" as that term is defined by Section 9785(a)(1).
(b) Any properly documented bill for medical treatment within the planned course, scope and duration of treatment reported under Section 9785 which is provided or authorized by the treating physician shall be paid by the claims administrator within sixty days from receipt of each separate itemized bill and any required reports, unless the bill is contested, as specified in subdivisions (d), and (e), within thirty working days of receipt of the bill. Any amount not contested within the thirty working days or not paid within the sixty day period shall be increased 10%, and shall carry interest at the same rate as judgments in civil actions retroactive to the date of receipt of the bill.
For purposes of this Section, treatment which is provided or authorized by the treating physician includes but is not limited to treatment provided by a "secondary physician" as that term is defined by Section 9785(a)(2).
(c) To be properly documented, a bill for medical treatment which exceeds the amount presumed reasonable in the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1, must be accompanied by an itemization and explanation for the excess charge.
(d) A claims administrator who objects to all or any part of a bill for medical treatment shall notify the physician or other authorized provider of the objection within thirty working days after receipt of the bill and any required report and shall pay any uncontested amount within sixty days after receipt of the bill. If a required report is not received with the bill, the periods to object or pay shall commence on the date of receipt of the bill or report, whichever is received later. If the claims administrator receives a bill and believes that it has not received a required report to support the bill, the claims administrator shall so inform the medical provider within thirty working days of receipt of the bill. An objection will be deemed timely if sent by first class mail and postmarked on or before the thirtieth working day after receipt, or if personally delivered or sent by electronic facsimile on or before the thirtieth working day after receipt. Any notice of objection shall include or be accompanied by all of the following:

(1) An explanation of the basis for the objection to each contested procedure and charge. The original procedure codes used by the physician or authorized provider shall not be altered. If the objection is based on appropriate coding of a procedure, the explanation shall include both the code reported by the provider and the code believed reasonable by the claims administrator.
(2) If additional information is necessary as a prerequisite to payment of the contested bill or portions thereof, a clear description of the information required.
(3) The name, address, and telephone number of the person or office to contact for additional information concerning the objection.
(4) A statement that the treating physician or authorized provider may adjudicate the issue of the contested charges before the Workers' Compensation Appeals Board.
(e) An objection to charges from a hospital, outpatient surgery center, or independent diagnostic facility shall be deemed sufficient if the provider is advised, within the thirty working day period specified in subdivision (d), that a request has been made for an audit of the billing, when the results of the audit are expected, and contains the name, address, and telephone number of the person or office to contact for additional information concerning the audit.
(f) Any contested charge for medical treatment provided or authorized by the treating physician which is determined by the appeals board to be payable shall carry interest at the same rate as judgments in civil actions from the date the amount was due until it is paid.

Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4603.2 and 5307.1, Labor Code.

s 9792.6. Utilization Review Standards -Definitions.
As used in this Article:
(a) "ACOEM Practice Guidelines" means the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, Second Edition.
(b) "Authorization" means assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment to cure or relieve the effects of the industrial injury pursuant to section 4600 of the Labor Code, subject to the provisions of section 5402 of the Labor Code, based on the Doctor's First Report of Occupational Injury or Illness," Form DLSR 5021, or on the "Primary Treating Physician's Progress Report," DWC Form PR-2, as contained in section 9785.2, or in narrative form containing the same information required in the DWC Form PR-2.
(c) "Claims Administrator" is a self-administered workers' compensation insurer, an insured employer, a self-administered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, a third-party claims administrator or other entity subject to Labor Code section 4610. The claims administrator may utilize an entity contracted to conduct its utilization review responsibilities.
(d) "Concurrent review" means utilization review conducted during an inpatient stay.
(e) "Course of treatment" means the course of medical treatment set forth in the treatment plan contained on the "Doctor's First Report of Occupational Injury or Illness," Form DLSR 5021, or on the "Primary Treating Physician's Progress Report," DWC Form PR-2, as contained in section 9785.2 or in narrative form containing the same information required in the DWC Form PR-2.
(f) "Emergency health care services" means health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy.
(g) "Expedited review" means utilization review conducted when the injured worker's condition is such that the injured worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decision-making process would be detrimental to the injured worker's life or health or could jeopardize the injured worker's permanent ability to regain maximum function.
(h) "Expert reviewer" means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical issues involved in the medical treatment services and where these services are within the individual's scope of practice, who has been consulted by the reviewer or the utilization review medical director to provide specialized review of medical information.
(i) "Health care provider" means a provider of medical services, as well as related services or goods, including but not limited to an individual provider or facility, a health care service plan, a health care organization, a member of a preferred provider organization or medical provider network as provided in Labor Code section 4616.
(j) "Immediately" means within 24 hours after learning the circumstances that would require an extension of the timeframe for decisions specified in subdivisions (b)(1), (b)(2) or (c) and (g)(1) of section 9792.9.
(k) "Material modification" is when the claims administrator changes utilization review vendor or makes a change to the utilization review standards as specified in section 9792.7.
(l) "Medical Director" is the physician and surgeon licensed by the Medical Board of California or the Osteopathic Board of California who holds an unrestricted license to practice medicine in the State of California. The Medical Director is responsible for all decisions made in the utilization review process.
(m) "Medical services" means those goods and services provided pursuant to Article 2 (commencing with Labor Code section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code.
(n) "Prospective review" means any utilization review conducted, except for utilization review conducted during an inpatient stay, prior to the delivery of the requested medical services.
(o) "Request for authorization" means a written confirmation of an oral request for a specific course of proposed medical treatment pursuant to Labor Code section 4610(h) or a written request for a specific course of proposed medical treatment. An oral request for authorization must be followed by a written confirmation of the request within seventy-two (72) hours. Both the written confirmation of an oral request and the written request must be set forth on the "Doctor's First Report of Occupational Injury or Illness," Form DLSR 5021, section 14006, or on the Primary Treating Physician Progress Report, DWC Form PR-2, as contained in section 9785.2, or in narrative form containing the same information required in the PR-2 form. If a narrative format is used, the document shall be clearly marked at the top that it is a request for authorization.
(p) "Retrospective review" means utilization review conducted after medical services have been provided and for which approval has not already been given.
(q) "Reviewer" means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical issues involved in medical treatment services, where these services are within the scope of the reviewer's practice.
(r) "Utilization review plan" means the written plan filed with the Administrative Director pursuant to Labor Code section 4610, setting forth the policies and procedures, and a description of the utilization review process.
(s) "Utilization review process" means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. Utilization review does not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining whether the medical services were accurately billed.
(t) "Written" includes a facsimile as well as communications in paper form.

Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 3209.3, 4062, 4600, 4600.4, 4604.5 and 4610, Labor Code.

s 9792.7. Utilization Review Standards -Applicability.
(a) Effective January 1, 2004, every claims administrator shall establish and maintain a utilization review process for treatment rendered on or after January 1, 2004, regardless of date of injury, in compliance with Labor Code section 4610. Each utilization review process shall be set forth in a utilization review plan which shall contain:
(1) The name, address, phone number, and medical license number of the employed or designated medical director, who holds an unrestricted license to practice medicine in the state of California issued pursuant to section 2050 or section 2450 of the Business and Professions Code.
(2) A description of the process whereby requests for authorization are reviewed, and decisions on such requests are made, and a description of the process for handling expedited reviews.
(3) A description of the specific criteria utilized routinely in the review and throughout the decision-making process, including treatment protocols or standards used in the process. A description of the personnel and other sources used in the development and review of the criteria, and methods for updating the criteria. Prior to and until the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section 5307.27, the written policies and procedures governing the utilization review process shall be consistent with the recommended standards set forth in the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, Second Edition. The Administrative Director incorporates by reference the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines (ACOEM), Second Edition (2004), published by OEM Press. A copy may be obtained from OEM Press, 8 West Street, Beverly Farms, Massachusetts 01915 (www.oempress.com). After the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section 5307.27, the written policies and procedures governing the utilization review process shall be consistent with the recommended standards set forth in that schedule. (continued)