Workers’ Compensation Injury Billing Forms

Workers’ Compensation injury treating physicians are familiar with several billing forms. We will acquaint you with billing forms relating to patients and medical professionals.

The National Uniform Claim Committee (NUCC) maintains the standard claim form, CMS-1500, to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) by non-institutional providers or suppliers. The CMS-1500 form bills patients for medical services that insurance does not cover, Centers for Medicare and Medicaid Services (CMS), and health insurers.

In addition, non-institutional providers and vendors, including ambulance services, clinical social workers, physicians, their assistants, clinical nurse specialists and practitioners, and psychologists, use the CMS-1500 form to submit medical claims.

However, the workers’ compensation system paperwork requirements are time-consuming. Therefore, consolidating and eliminating certain medical billing forms into the CMS-1500 form reduces administrative hindrance and increases provider participation.

The Workers’ Compensation Board replaced the following forms with the CMS-1500:

  • Doctor’s Initial Report (Forms C-4, EC-4)
  • Continuation to Carrier/Employer Billing Section (Form C-4.1)
  • Doctor’s Progress Report (Forms C-4.2, EC-4.2)
  • Ancillary Medical Report (Forms C-4AMR, EC-4AMR)
  • Doctor’s Narrative Report (Form EC-4NARR)
  • Occupational/ Physical Therapist’s Report (Forms OT/PT-4, EOT/PT-4)
  • Psychologist’s Report (Form PS-4)
  • Ophthalmologist’s Report (Form C-5)

The physician’s initial narrative report requirements include submitting a CMS-1500, a C4 form, and a medical narrative. To present a narrative, the physician must utilize a clearing house with an XML submission partner. The narrative must include:

  • The work status.
  • Temporary impairment.
  • An opinion or causation history of injury or illness.
  • Objective findings.
  • Diagnosis or assessment.
  • A listed plan of the first three work statuses.

In addition, the beginning of the narrative report must include a temporary impairment and an opinion of the causation of the illness or injury.

The physician must include their rating and authorization number with the demographic information at the top of the narrative report. In addition, the Board’s website provides narrative reports.

The physician must include the patient’s work status in the first portion of the narrative report with the following information:

  • Determine if the patient’s illness or injury has caused lost time at work. If so, provide the first date of lost work.
  • Provide the dates the patient resumed full-time or limited employment.
  • Specify if the patient may resume regular work activities as suggested if they are not working.
  • Evaluate for any work-related restrictions and describe them in detail, including expected length.

Only a physician may add temporary impairment to a patient’s medical narrative. Therefore, determine the temporary impairment percentage from zero to 100%. In addition, describe an explanation of how to choose the impairment percentage.

The top of the physician’s narrative report must provide the physician’s opinion, including

  • Indicate if the patient’s incident describes a competent medical cause of the injury or illness.
  • Indicate the consistency of the patient’s complaints and the injury or illness history.
  • Indicate the consistency of the patient’s history with the objective findings, if applicable.

The Distinction Between a Clearing House and an XML Submission Partner

Once a clearing house receives XML submission approval it is considered an XML submission partner. Then, healthcare providers may partner with an approved XML submission partner or verify that their clearing house has a data-sharing agreement.

The XML submission process determines how an approved XML submission partner submits the CMS-1500 form to the Board. For example, providers may electronically submit medical bills and narratives to their clearinghouse, submitting CMS-1500 data and forms within the required XML format.

Current lists of XML submission partners are available on the Board’s homepage by utilizing the search feature. In addition, contact providers by XML submission partners to assist with testing.

A physician may request their clearinghouse to participate if not located on the Board’s website. In addition, the Board provides more information, initiative overview, registration information, sample documents, and current forms of crosswalks. Providers must understand that an electronic signature holds the same weight as a paper signature.

However, an electronic submission requires a signature each time when using electronic submission. An electronic process or symbol may comprise a party’s signature when attached to or associated with an electronic record and executed or adopted by a person when attempting to sign the record for additional details.

Submit medical bills within 90 days from the last day of the month which rendered services or the claimant received final treatment of a continuous course of treatment. An XML submission partner has up to seven business days to forward the bill and narrative report to the payer and the Board.

However, the XML submission partner must provide notification if the payer or the Board rejects the bill. The provider must ensure timely corrections to rejected bills and resend them to the payer and the board.

Refer to your state’s Workers’ Compensation Board website or speak with a Workers’ Compensation attorney for additional information.

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

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