When the Official Medical Fee Schedule (OMFS) assigns the reimbursement for a procedure code as “By Report” (BR), establishing the correct payment amount is one of the trickier aspects of California workers’ compensation billing.
For codes designated a BR reimbursement, the Division of Workers’ Compensation (DWC) does not assign a specific reimbursement amount. Instead, the provider must determine and request a reasonable amount for these procedures from the employer or insurer’s claims administrator.
To help providers determine and obtain the correct reimbursement for these codes, we’ve put together this “By Report” reimbursement guideline.
The OMFS designates the reimbursement amount for a procedure code as “BR” in the following situations:
In any of the above scenarios, the fee schedule offers no base maximum fee for the procedure code in question. The provider must determine a reasonable charge — and thus reimbursement — as instructed in California Code of Regulations (CCR) 9789.12.4 (more on that below).
CCR § 9789.12.4 offers guidelines to determine an appropriate reimbursement amount for BR codes. Essentially, the regulation instructs providers to find a comparable procedure, one similar in the amount of time, skill, and resources required. The BR reimbursement amount should be comparable to the reimbursement for the comparable code:
Basing BR reimbursements on “comparable procedures or analogous codes” is not a requirement per se, but the DWC’s suggestion. However the provider determines reimbursement, that provider must justify the chosen amount with a separate, non-reimbursable report.
The report must be sufficient in detail to support both the application of the procedure and the requested reimbursement. Per the regulation, it must establish that the procedure was “reasonable and necessary to cure or relieve from the effects of the industrial injury or illness.” To support the reimbursement amount, the report must also document:
The most secure, hassle-free way providers can guarantee reasonable reimbursement for procedure codes assigned a BR as the reimbursement is to enter into a contractual agreement with the employer or insurer’s claims administrator.
California Labor Code Section 5307.11 establishes the right of payors and providers to mutually agree to reimbursement amounts outside the fee schedule — especially useful when the fee schedule offers no reimbursement amount:
This rule has one extremely important requirement, however: the contract must be established prior to providing the service. The provider must establish reasonable reimbursements for BR codes in writing, and have the claims administrator initial each reimbursement amount individually before signing the document.
While providers can still determine and request reasonable BR reimbursements without a signed agreement, doing so leaves the door open for disputes that require Independent Bill Review (IBR) to resolve. In the long run, securing a signed agreement is worth the initial effort.
We offer a downloadable, printable sample document for establishing contractual rates for BR codes. Providers can easily fill this form in with the relevant procedure codes and reimbursement rates.
It’s unfortunate that even the task of determining some reimbursements, along with the other myriad burdens of workers’ comp billing, somehow falls on the provider. In summation, to secure proper, reasonable reimbursement for BR codes, we recommend taking the following steps:
With a signed agreement secured, your office is guaranteed a fair rate of reimbursement for BR procedure codes. Be sure to factor any change in reimbursement rates for analogous procedure codes into your own rates, and update your agreements if necessary.
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