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CA Cheat Sheet: Required Reports & Supporting Documentation for Workers' Comp Bills

CA Cheat Sheet: Required Reports & Supporting Documentation for Workers' Comp Bills

In California, when submitting a bill for treating an injured worker, it’s imperative to include the correct documentation to support the treatment. If the provider fails to include any of the required separate reports or other documents, the claims administrator will keep the provider’s reimbursement — by simply denying the bill as incomplete.

To help providers ensure correct payment, below is a reference guide to the required reports and supporting documentation specified in California workers’ comp regulations.

Required Reports & Documents for CA Workers’ Comp Bills

The Division of Workers’ Compensation (DWC)’s Medical Billing and Payment Guide specifies 12 events or circumstances in which a separate report/document must accompany the provider’s bill, as reflected in the table below.

Note that a narrative report may be an acceptable alternative to certain standardized reporting forms, such as the PR-2, PR-3, and PR-4. However, narrative reports are subject to strict requirements. To review narrative report requirements, refer to Table 2 in this post.

Also note that of the 12 events or circumstances below, 2 are subject to further requirements found in California Code of Regulations (CCR) Section 9785. To determine CCR §9785 report requirements, refer to Table 3 in this post.

Table 1: DWC-Required Reports & Documentation

Required Reporting/Documentation

Event/Circumstance

Doctor’s First Report of Occupational Injury (DSLR Form 5021)

E/M services rendered and CCR §9785* requires the Doctor’s First Report of Occupational Injury

Primary Treating Physician’s Progress Report (DWC Form PR-2 or narrative report**)

E/M services rendered and CCR §9785* requires Primary Treating Physician’s Progress Report

Primary Treating Physician’s Permanent and Stationary Report (DWC Form PR-3 or narrative report** when Date of Injury is before 1/1/2005; DWC Form PR-4 or narrative report** when Date of Injury is on or after 1/1/2005)

E/M services rendered, and the patient’s condition is declared permanent and stationary with permanent disability or need for future medical care

Narrative Report

E/M services rendered for a consultation

Report sufficient to justify modifiers

Provider uses Modifiers -22, -23, or -25

Descriptive Report of the procedure, drug, or DME

Provider uses any billing code payable “By Report

Descriptive Report of service rendered

The Official Medical Fee Schedule (OMFS) indicates that a report is required for the billing code used

Operative Report

Professional or facility Surgery Services rendered

Invoice or proof of documented paid costs

When required by statute or OMFS

Requested report or documentation

The claims administrator reasonably requests additional information to support a billed code prior to bill submission

Proof of authorization

All bills must be accompanied by documentation that the services billed were authorized

Prescription or referral from PTP

Services rendered were not performed by the PTP

*See Table 3 for CCR §9785 requirements

**See Table 2 for narrative equivalent requirements

Table 2: Narrative Report Requirements

Report

Standardized Form

Acceptable Equivalent

Requirements

Primary Treating Physician’s Progress Report

DWC PR-2

Narrative Report

  1. Must be titled “Primary Treating Physician’s Progress Report” in bold-faced type
  2. Must indicate clearly the reason the report is being submitted
  3. Must contain the same information and subject headings as PR-2, in the same order as PR-2
  4. Must include the following declaration: “I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code § 139.3.”

Primary Treating Physician’s Permanent and Stationary Report

DWC PR-3 (for dates of injury prior to 1/1/2005)

DWC PR-4 (for dates of injury on or after 1/1/2005)

Report in “such other manner which provides all the information required by” CCR Section 10682

Report must include:

  1. Date of examination
  2. History of the injury
  3. Patient's complaints
  4. All information received in preparation of the report or relied upon for formulation of the physician's opinion
  5. Patient's medical history, including injuries and conditions, and residuals thereof, if any
  6. Findings on examination
  7. Diagnosis
  8. Opinion as to the nature, extent and duration of disability and work limitations, if any
  9. Cause of the disability
  10. Treatment indicated, including past, continuing and future medical care
  11. Opinion as to whether or not permanent disability has resulted from the injury and whether or not it is stationary. If stationary, a description of the disability with a complete evaluation
  12. Apportionment of disability, if any
  13. Determination of the percent of the total causation resulting from actual events of employment, if the injury is alleged to be a psychiatric injury
  14. Reasons for the opinion
  15. Physician’s signature

Table 3: Reporting Requirements of CCR §9785

Several reporting requirements in the DWC Medical Billing and Payment guide reference CCR §9785. As such, the table below breaks down exactly when CCR §9785 mandates a report.

Required Report

Service/Situation

DSLR Form 5021:‘Doctor’s First Report of Occupational Injury or Illness’

Within 5 days of initial treatment by Primary Treating Physician (PTP), or following treatment by emergency or urgent care physician

PR-2: Primary Treating Physician’s Progress Report (or narrative report)

Within 20 days* of the following events:

  • Unexpected significant change in employee’s medical condition
  • Employee’s condition permits return to work
  • Employee’s condition requires leaving work, or new restrictions/modifications are necessary to continue work
  • Employee is released from medical care
  • Employee’s condition precludes or is likely to preclude a return to the occupation
  • A medical examination occurs

PR-2: Primary Treating Physician’s Progress Report (or a letter from the provider)

Claims admin reasonably requests more information deemed “necessary” to administer the claim, as defined by Labor Code Section 139.3

*During continued medical treatment, a PR-2 or narrative report is required every 45 days if no other event requiring a PR-2 has occurred


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