§ 9789.12.4 “By Report” - Reimbursement for Unlisted Procedures / Procedures Lacking RBRVUs

Summary

Calculating OMFS reimbursement is a complex process that involves multiple tables, formulas and Billing Ground Rules. The OMFS Calculator takes into consideration all of these factors when providing OMFS reimbursement.

The DWC mandates that an unlisted procedure code is paid “By Report”, following review of documentation. The necessary conditions for billing “By Report” include:

  • The service was reasonable and necessary to cure or relieve from the effects of the industrial injury or illness.
  • The bill includes an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.

California Code of Regulations (CCR)

§ 9789.12.4 “By Report” - Reimbursement for Unlisted Procedures/Procedures Lacking RBRVUs

Division of Workers’ Compensation Websites

Official Medical Fee Schedule

DaisyBill Resources

If a California workers’ comp fee schedule designates the reimbursement amount for a procedure code entered on a Bill as ‘By Report’ (BR), DaisyBill’s scrub prevents bill submission until a reimbursement amount is entered for the procedure code.

DaisyBill OMFS Calculator

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