At DaisyBill, our clients ask us for help when claims administrators improperly deny reimbursement. Recently, our clients have reported that some claims administrators are denying payment for ultrasound examinations unless a copy of the permanent image is sent as part of the required billing documentation.

Allow us to clear this up. There is absolutely no billing requirement for California providers to include the actual images when billing for ultrasounds.

Required Documentation for Workers’ Comp Bills

Claims administrators do not determine the requirements for a complete bill. Only California’s Division of Workers’ Compensation (DWC) can play that role. The DWC Medical Billing and Payment Guide lays out these billing requirements, regardless of any claims administrator’s whim.

Section 3.0(b) of the Medical Billing and Payment Guide explicitly provides instructions for “required reports and supporting documentation sufficient to support the level of service or code that has been billed.” In the entire section, the DWC identifies 7 required supporting documentations:

1. Standard reporting forms (like the Doctor’s First Report and PR-2, PR-3, and PR-4 reports)
2. Narrative reports
3. Descriptive reports
4. Operative reports
5. Invoices or other proof of documented paid costs (but ONLY when required by Statute or by the OMFS. For example, “DME: Invoice Not Required for (Most) Durable Medical Equipment”)
6. Copies of prescriptions (exception: Pharmacy services)
7. Copies of referrals

And while § 3.0(b) allows for PRIOR to submission of the billing: “appropriate information reasonably requested by the claims administrator,” no regulation regarding imaging services requires images or copies thereof. For a claims administrator to deny payment for imaging services is neither “appropriate” nor “reasonable.”

Ultrasound Documentation

For ultrasound examinations specifically, the required supporting documentation stems from the CPT code book, published by the American Medical Association (AMA). The AMA CPT code book is adopted into California workers’ comp regulations by reference.

The reporting requirements for the various ultrasound codes are consistent, and include:

• A thorough evaluation of organ(s) or anatomic region
• Image documentation
• A final, written report

“Image documentation” does not refer to a copy of the image itself. It refers to the appropriate written reporting as outlined in the Billing and Payment Guide. For billing purposes, providers must document a permanent image captured via ultrasound, not provide it. If the claims administrator claims otherwise, submit a timely Second Review appeal.

We can’t make workers’ comp rules less complicated. We can make them easier to navigate. Our Billing Software makes authorization, billing, and appeals less of a headache for providers. Request a free demonstration, and see how.

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