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.
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.
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
Report |
Standardized Form |
Acceptable Equivalent |
Requirements |
Primary Treating Physician’s Progress Report |
DWC PR-2 |
Narrative Report |
|
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:
|
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:
|
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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