Understanding the Difference Between 99080 and WC007

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Understanding the Difference Between 99080 and WC007

Everything changed when the Division of Workers’ Compensation adopted the RBRVS-based Physician Fee schedule on January 1, 2014. We don’t say that to be dramatic – everything did change, and medical providers across the state are still learning to adapt three years later. Today, we’re focusing on a specific consequence of the shift to RBRVS: The elimination of CPT 99080 as a reimbursable code for consultation reports, and the erroneous use of California-specific code WC007 in its place.

For all dates of service on or after January 1, 2014, CPT Code 99080 is assigned a Status Code B (denoting a bundled code), rendering it no longer payable. To compensate, many physicians incorrectly use California-specific code WC007 to bill for consultation reports, believing these two codes function as equals. Not so. Although WC007 is used for consultation reports, separate reimbursement for this California-specific code is severely restricted. In most circumstances – say when a provider is referred a patient by an adjuster, attorney, or another provider – reimbursement for the consultation report is bundled into that for the underlying evaluation and management.

The DWC created code WC007 in deference to two recognized incidences when a consultation report is required, but cannot be bundled into an underlying service code as required by the RBRVS-based Physician Fee Schedule. The complexity inherent to workers’ comp necessitates such a code, but it’s important to understand that WC007 only applies to two special situations.

Per the DWC’s Physician Fee Schedule Regulations, set down in Title 8 of the California Code of Regulations, WC007 should only be billed under the following circumstances:

  • When a consultation report is requested by the Workers’ Compensation Appeals Board (WCAB), or by George Parisotto, the DWC’s Administrative Director. In this case, providers are instructed to use code WC007 along with the modifier -32.
  • When a consultation report is requested by a QME or AME as part of a medical-legal evaluation. In this case, providers use code WC007 with the modifier -30.[1]

The DWC sets new reimbursement amounts for its California-specific codes annually. The 2017 reimbursement for code WC007 is set at $39.89 for the first page of the report, and $24.54 for each additional page. Absent mutual agreement, these reports are capped at a six-page maximum.

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[1] See Division 1, Chapter 4.5, Subchapter 1 of the Physician Fee Schedule Regulations.

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