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Required Supporting Documentation for California Workers’ Comp Bills

March 16, 2017 by Catherine Montgomery

Yesterday on the blog, we broke down the differences between the California Division of Workers’ Compensation (DWC) forms PR-3 and PR-4 for Primary Treating Physicians. Today, we broaden our focus to include other required supporting documents for workers’ comp bills, along with the circumstances under which each should be used.

The DWC Medical Billing and Payment Guide provides strict guidelines for what constitutes a “complete” bill submission. To start with, the bill must be completed on the proper form, using valid billing codes.

Billing Form

Used By

CMS 1500

Physicians and Professional Health Care Providers

Providers of DMEPOS

Pharmacies billing for DMEPOS

Clinical Laboratories

Ambulance Service Providers

UB-04

Inpatient Hospitals

Rehabilitation Hospitals

Hospital Outpatient Departments

Ambulatory Surgical Center

NCPDP

Pharmacies (Except when billing for DMEPOS)

ADA Dental Claim Form

 

Dentists

Dental Clinics

Orthodontists

Beyond that, complete bills must include the necessary supporting documentation and reports, as set out by the DWC and in Title 8, California Code of Regulations § 9785: Reporting Duties of the Primary Treating Physician. We’ll take them one by one.

Doctor’s First Report of Occupational Injury: DSLR 5021

After a Primary Treating Physician performs an initial evaluation of an injured worker, they have five business days to submit a DSLR 5021 report to the claims administrator.

Per the report, the physician must include relevant information about his or her planned course of treatment and future services.

Emergency and urgent care physicians must also submit Form 5021 within 5 working days of the injured worker’s initial examination. In the event that the Primary Treating Physician for a particular injured employee changes at any point throughout that employee’s treatment, each new PTP must submit a DSLR 5021 report.

A link to the DWC’s Form DSLR 5021 is available on our website:

Primary Treating Physician’s Progress Report: DWC PR-2

In the case of continuing medical treatment, PTPs must file periodic progress reports with the claims administrator using the DWC’s PR-2 Form. California Code of Regulations § 9785 identifies eight conditions that warrant a PR-2 report:

(1) The employee's condition undergoes a previously unexpected significant change;

(2) There is any significant change in the treatment plan reported, including, but not limited to, (A) an extension of duration or frequency of treatment, (B) a new need for hospitalization or surgery, (C) a new need for referral to or consultation by another physician, (D) a change in methods of treatment or in required physical medicine services, or (E) a need for rental or purchase of durable medical equipment or orthotic devices;

(3) The employee's condition permits return to modified or regular work;

(4) The employee's condition requires him or her to leave work, or requires changes in work restrictions or modifications;

(5) The employee is released from care;

(6) The primary treating physician concludes that the employee's permanent disability precludes, or is likely to preclude, the employee from engaging in the employee's usual occupation or the occupation in which the employee was engaged at the time of the injury;

(7) The claims administrator reasonably requests appropriate additional information that is necessary to administer the claim. “Necessary” information is that which directly affects the provision of compensation benefits as defined in Labor Code Section 3207.

(8) When continuing medical treatment is provided, a progress report shall be made no later than forty-five days from the last report of any type under this section even if no event described in paragraphs (1) to (7) has occurred. If an examination has occurred, the report shall be signed and transmitted within 20 days of the examination.”

PTPs may choose to submit this report in narrative form, providing that it presents the same information of the DWC PR-2 form, in the same order.

The DWC PR-2 Form is available for download on our website:

Primary Treating Physician’s Permanent and Stationary Report: DWC PR-3 and PR-4

When the Primary Treating Physician determines that the injured employee's condition is both permanent and stationary, the PTP must issue either a PR-3 or PR-4 report[a] – or their narrative equivalent – to the claims administrator within 20 days from the date of examination of the injured employee. These reports contain detailed information about the extent of the permanent injury and the need for ongoing or future treatment.

Choosing between these reports is often as simple as knowing the date of the injury. The PR-3 report is used for injuries pursuant to the 1997 edition of the Permanent Disability Rating Schedule (PDRS), and is therefore generally used for injuries that occurred on or before December 31, 2004. The PR-4 report, on the other hand, is used for injuries pursuant to the 2005 edition of the Permanent Disability Rating Schedule (PDRS). In other words, you should choose the PR-4 report if the date of injury is on or after January 1, 2005.

Physicians who choose to submit these reports in narrative form must meet certain requirements set out in Section 10606 of the California Code of Regulations.

Both forms are available for download from our website:

Other Required Reports

Though the DWC does not provide standardized forms for every report type, there are still an array of other scenarios in which a PTP report is a required in support of a workers’ comp bill.

Scenario

Report Type

A physician provides an Evaluation and Management consultation.

Narrative Report

The provider uses any of the following modifiers: – 22, – 23, or – 25.

Descriptive Report

The provider uses a code that is designated payable “By Report,” per the OMFS.

Descriptive Report of the procedure, including treatment type, procedure length, equipment used, and level of skill necessary to perform the treatment. More information is available on our blog[b].

The OMFS indicates that a report is required.

Descriptive Report

The provider furnished either professional or facility Surgery Services.

Operative Report

The OMFS requires an invoice or proof of cost for reimbursement.

Invoice or Proof of Documented Paid Costs

A claims administrator or claims administrator agent requested additional information in support of a billed code prior to bill submission.

Varies by Request

The provider submits a paper bill

Any written authorization for services received by the physician.

                                                                                        


Want to learn more about California workers’ comp bills? Watch our webinar below on the new reimbursable CPT Codes (99358 and 99359) for record review and other non-face-to-face services.

CPT Codes 99358 & 99359 Webinar

[a]Link to blog

[b]Link to BR post

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