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Work Comp Billing: How to Bill for P&S Reports (Do Not Use ML102!)

January 30, 2018 by Catherine Montgomery

Some providers mistakenly believe that Permanent and Stationary (P&S) reports are billable with medical-legal billing code ML102 for Basic Comprehensive Medical-Legal Evaluations. This is incorrect and noncompliant. Worse, the Division of Workers’ Compensation (DWC) can deem billing P&S reports with ML102 an act of fraud, with potentially serious legal consequences.

Providers, be sure to stay compliant. Here’s how to bill properly for P&S Reports.

Following treatment, every injured worker reaches a point at which treatment will no longer improve their condition. Ideally, that point is full recovery. But when a provider cannot expect the injured worker to ever recover completely, they deem the injury “permanent and stationary”  (P&S). Such an injury has reached a point of “maximum medical improvement” that is short of a full recovery.  

In such cases, the provider issues a P&S report to help determine appropriate benefits. The report includes provider assessments of the work-relatedness of the injury, resultant work limitations and restrictions, and required continued medical care. The provider shares the report with the employer or insurer’s claims administrator, and the injured worker.

This report is compensable. It is not, however, a Basic Comprehensive Medical-Legal Evaluation.

Applying ML102 to P&S reports gives the claims administrator valid grounds on which to deny the bill and any request for second review. The denial will likely be upheld in Independent Bill Review (IBR). More importantly, it’s technically it may be an act of fraud — one on which the DWC is lately cracking down.

Billing Codes for P&S Reports

A P&S report should be billed as an established patient visit, using CPT codes 99212-99215 and the appropriate WC report code. The WC codes are billed per unit, with one unit equal to one page of the P&S report. Per California Code of Regulations (CCR) § 9785, the date of injury determines the appropriate form, WC code, and maximum number of billable pages:

Date of Injury

Form

WC Code

Reimbursement as of 1/1/18

(First Page/Unit)

Reimbursement as of 1/1/18 (Each Additional Page/Unit)

On or before 12/31/2004

PR-3

WC003 (1 unit = 1 page)

$40.45

$24.88 (Maximum 6 pages absent mutual agreement)

On or after 1/1/2005

PR-4

WC004 (1 unit = 1 page)

$40.45

$24.88 (Maximum 7 pages absent mutual agreement)

Providers can download the PR-3 and PR-4 forms by clicking the links in the table above. Alternately, providers may issue the narrative equivalent of the PR-3 or PR-4 form, subject to the requirements of CCR §10606. If issuing a narrative report, be sure to include:

  1. Examination date
  2. Injury history
  3. Patient complaints
  4. A listing of all information received in preparation of the report or relied upon for the formulation of the physician's opinion
  5. Patient 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. 15. Physician signature

Refer to this guide whenever your office needs to issue a P&S report. As always, we’ll keep our readers updated on any new changes to rules and reimbursements for workers’ comp billing.


Get the reimbursement right, every time. DaisyBill offers a full suite of cloud-based billing software to help providers easily obtain the correct reimbursement. Schedule a free demonstration today, and see how DaisyBill can improve your bottom line.

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