One of DaisyBill’s biggest goals is to help medical professionals across California manage the nuances of the Official Medical Fee Schedule (OMFS). To that end, we spill a lot of ink covering changing workers’ comp reimbursements here on our blog. Beyond that, our Work Comp Wizard, around which every other DaisyBill product is built, features an always-accurate OMFS Calculator at its core.

In rare instances, the OMFS for the Physician Fee Schedule fails to provide a reimbursement amount for valid procedure code with directions that the reimbursement is established By Report, also known as a “BR” reimbursement. For these By Report procedure codes, providers may bill – and expect to be reimbursed – at any amount that they establish. But there’s a catch: The billed value must be deemed “reasonable” for the code in question.

Before we get any further, it’s important to review the reasons why the Physician Fee Schedule assigns reimbursement for a procedure code as By Report.  A procedure code reimbursement is deemed BR for one of the following four reasons:

1. The procedure code is listed in the Current Procedural Terminology (CPT), but is unlisted in the CMS National Physician Fee Schedule Relative Value File. The procedure code is not subject to Fee Schedules § 9789.30-9789.70.
2. The procedure code has a status indicator C, N, I or R and does not have an assigned RVU.
3. The procedure code has a status indicator E and:

1. Does not start with ‘J’ or ‘P’
2. Fee Schedules § 9789.30-9789.70 do not apply

4. The procedure code has a status indicator X and Fee Schedules § 9789.30-9789.70 do not apply.

Required BR Documentation

Once a provider verifies that the reimbursement for a procedure code is By Report, California Code of Regulations § 9789.12.4 provides billing instructions for these BR codes. This regulation lays out basic framework for justifying the provider’s reimbursement value for a BR Code. If the procedure is similar in time, complexity, or skill to another, billable CPT Procedure Code, it’s generally expected that the reimbursement for the BR code should be similar to that of the billable code.

In order to justify the BR reimbursement amount, a provider must submit a separate, non reimbursable report that must document the following:

• Satisfactorily prove “that the service was reasonable and necessary to cure or relieve from the effects of the industrial injury or illness.”^[1]
• Describe the procedure in as much detail as possible, including information about

• the length of the procedure,
• any equipment used, and
• the level of expertise or skill needed to perform the procedure. This information should be submitted via a separate, non-reimbursable report.

Stay tuned in the coming weeks for an analysis of the most commonly-used BR codes of 2016.

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