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.
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 |
WC003 (1 unit = 1 page) |
$40.45 |
$24.88 (Maximum 6 pages absent mutual agreement) |
|
On or after 1/1/2005 |
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:
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.
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