California Workers’ Compensation Resources
The COA provides its members with this Workers’ Compensation Resource Center to assist you in navigating California’s Workers’ Compensation system — Treatment and Medical-Legal.
Treatment – Official Medical Fee Schedule – Physician and Nonphysician Services
In 2017, the OMFS has fully transitioned to Medicare’s RBRVS system. The fee schedule now is based on a single conversion factor. Reimbursement is set at, on average, 120% of Medicare’s 2012 Fee Schedule. The Fee Schedule is also annually adjusted based on an average Medicare geographic adjustment and the annual Medicare Economic Index adjustment.
California has also adopted unique California billing codes to bill for reimbursable reports. New in 2017, is the ability to again bill the prolonged service codes for non-face-to-face time for reviewing medical records, etc. You have to spend at least 31 minutes before you can bill for the initial 60 minutes of time. Documentation of the time spent is required.
COA publishes a calculated OMFS so that members do not need to individually do the calculations. Starting in 2019, DWC is using the Medicare Geographic Practice Cost Indexes for each region. The most current OMFS can be found below.
California-Specific Codes
| WC001 Doctor’s First Report of Occupational Illness or Injury (Form 5021) (Section 9789.14(a)(1)) |
Not reimbursable |
| WC002 Treating Physician’s Progress Report (PR-2 or narrative equivalent in accordance with § 9785) (Section 9789.14(b)(1)) |
$15.72 |
| WC003 Primary Treating Physician’s Permanent and Stationary Report (Form PR-3) (Section 9789.14(b)(2)) |
$48.69 for first page. $29.93 each additional page. Maximum of six pages absent mutual agreement ($198.34) |
| WC004 Primary Treating Physician’s Permanent and Stationary Report (Form PR-4) (Section 9789.14(b)(3)) |
$48.69 for first page. $29.93 each additional page. Maximum of seven pages absent mutual agreement ($228.27) |
| WC005 Psychiatric Report requested by the WCAB or the Administrative Director, other than medical-legal report. Use modifier -32 (Section 9789.14(b)(4)) |
$48.69 for first page. $29.93 each additional page. Maximum of six pages absent mutual agreement ($198.34) |
| WC007 Consultation Reports Requested by the Workers’ Compensation Appeals Board or the Administrative Director (Use modifier -32) Consultation Reports requested by the QME or AME in the context of a medical-legal evaluation (Section 9789.14(b)(5)). (Use modifier -30) |
$48.69 for first page. $29.93 each additional page. Maximum of six pages absent mutual agreement ($198.34) |
| WC008 Chart Notes (Section 9789.14(c)) |
$14.07 for up to the first 15 pages. $0.29 for each additional page after the first 15 pages. |
| WC009 Duplicate Reports (Section 9789.14(d)) |
$14.07 for up to the first 15 pages. $0.29 for each additional page after the first 15 pages. |
| WC010 Duplication of X-Ray |
$6.45 per x-ray |
| WC011 Duplication of Scan |
$14.07 per scan |
| WC012 Missed Appointments |
No Fee Prescribed/Non-Reimbursable absent agreement |
For additional details on the OMFS, CA-unique codes, and all other fee schedules, go to the DWC website.
Medical-Legal Fee Schedule
The Medical-Legal Fee Schedule was last updated on April 1, 2021. The Medical-Legal Fee Schedule was completely revamped with new billing codes, including codes for billing the records sent to the evaluator. No longer is the fee schedule based on complexity factors. Reimbursement for the evaluations were also increased approximately 25%-30%. Revised Medical-Legal Fee Schedule.
COA Billing Guide
DWC Course for QMEs – NEW
Evaluating California’s Injured Workers: Qualified Medical Evaluators (QME)
Sample Medical-Legal Reports
- COA Sample Template Report NEW
- Template Report/DWC Checklist
- Sample 1
- Sample 2
- Sample 3
- Sample Supplemental Report NEW
Medical Treatment Utilization Schedule
Treatment rendered for injured workers under California’s Worker’s Compensation must be consistent with the Medical Treatment Utilization Schedule (MTUS) (largely based on the ACOEM Treatment Guidelines). If the procedure is not covered by the MTUS, treatment must be consistent with ODG treatment guidelines or other evidence-based nationally recognized guidelines.
UR Review Checklists
To assist our members in documenting conservative treatment, COA has developed a series of Workers’ Compensation Utilization Review Checklists. The checklists can be found at https://coa.org/education/ur-checklists/
UR Feedback Form
In addition, COA has established UR Feedback Form for members to report Good or Bad UR Experiences – https://coa.org/workers-comp-ur-feedback-form/
Request for Authorization/Drug Formulary
You must submit a Request for Authorization (RFA) to request treatment/pharmaceuticals. The RFA form can be found in the DWC forms.
Drug Formulary
By January, 2018, the DWC is expected to release a drug formulary which will also be tied to the ACOEM treatment guidelines. COA has successfully argued that medications needed for post-surgical patients immediately following surgery should be exempted from the prior authorization requirement. A limited number of medications is expected to be included on the “Preferred Drug” list requiring no authorization.
California Division of Workers’ Compensation Forms
Work Status Report (Word Document – editable form) (PDF)
AMA Guides to the Evaluation of Permanent Impairment (Webinar)
Assessing Pain
The AMA Guides 6th Edition includes a pain disability questionnaire that will help you score a patient’s pain levels. Even though the AMA has released the 6th Edition of the AMA Guides, you would only use the 6th Edition to evaluate disabilities for federal employees. For all other injured workers, continue to use the 5th Edition of the AMA Guides.
In addition, you can use this patient’s pain drawing to help patients describe to you where they are feeling pain.
