Workers’ Compensation Reimbursement in 2019

California Providers: have you noticed a change in reimbursement for your Workers’ Compensation claims? 2019 brought changes to the reimbursement formula for the Official Medical Fee Schedule (OMFS), which was already complicated enough to navigate for providers.

The Change

The California Division of Workers’ Compensation (DWC) has altered their reimbursement formula so it now adjusts for your region. In prior years, the reimbursement was consistent state-wide using the Average Statewide Geographic Adjustment Factor (GAF). They are now accounting for your region with what is called the Geographic Practice Cost Index (GPCI). You can find your GPCI here.

The nitty gritty of it means their calculation went from:

[(Work RVU * Statewide Work GAF) +(Non-Facility PE RVU * Statewide PE GAF) + (MP RVU * Statewide MP GAF)] * Conversion Factor (CF) = Base Maximum Fee


[(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor (CF) = Base Maximum Fee

What it Means in Practice

Because staring at a formula may not give you the information you need in practice, what you need to know is:

  • Most regions in California will actually see a decrease in Workers’ Compensation reimbursement with the introduction of GPCI; as much as a 4% reduction. Examples of these regions: Modesto, Bakersfield, Fresno, San Diego.
  • Regions with a higher GPCI can expect an increase of 8-10%. Examples of these regions: Alameda and Contra Costa County, Santa Clara County, San Francisco and San Mateo County.
  • GPCI does not affect most of the codes exclusive to Workers’ Compensation (outside of CPT) such as your codes for Primary Treating Physicians Report – PR-2 – billed as WC002. Those codes are set yearly, and are paid the same fee statewide. You can find these rates in the official text of regulations, pages 56-57.

To ensure you are being paid properly, adjust your current method of calculation to remove the GAF and replace them with your specific GPCI. If you currently have no method of calculating your expected Workers’ Comp reimbursement, don’t worry, you are likely in the majority. You can set up a spreadsheet using the formula above, and the factors for the formula are published for each CPT code. If you need clarification on the factors that go into the formula you can always take a look at the text of regulations from the DWC.

Need More Help?

We absolutely understand that the technical information given above can feel overwhelming. We exist to help you! Contact In Charge Office Solutions below to see how our services can relieve your administrative headaches. You can also always give us a call at (925)398-8635.


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Care Plans: Key to Medicare Chiropractic Reimbursement

Care plans have always been important in Chiropractic billing to Medicare, and that was only reinforced in 2018 with their changes to reporting Physical Therapy codes.

“454 Qualifier”

Medicare has long required Chiropractors send the date of the current care plan on their claims. This is referred to as the “454 Qualifier.” This is not to be the date of injury, but rather the date you first created the care plan for the patient. If the patient presents with a new issue and a new care plan is created, don’t forget to update this date in your Practice Management system.

Physical Therapy Coding

Beginning in 2018, Medicare requires physical therapy coding be sent with modifier “GP” when “services are delivered under an outpatient physical therapy plan of care.” Without this modifier, Medicare rejects processing of this code set when sent by Chiropractors.

Why does this matter if Medicare does not cover these services for Chiropractors anyway? For a few reasons.

  1. If you render the services and Medicare does not even process them, that means they are not crossed over to the secondary plans and they are processed to provider liability. Many patients have secondary plans that will cover these services if they are processed to patient responsibility.
  2. Even in the absence of a secondary plan, if you are intending on charging the patient for services rendered, you will need the EOB to process to patient responsibility.

For a line item example, sending your claim as:

97140-GP-GX will process on the EOB to patient responsibility.

Sending your claim as:

97140-59 or 97140-XS will now return as provider liability.

In Short:

  • Be mindful of ensuring you have current care plans on file and those dates current in your billing system. Medicare does not require your care plans be sent with your claim, only the date.
  • Update your software programs to include “GP” when physical therapy is rendered under the care plans.

The “End of Flexibility” for ICD 10

Unspecified Codes Now Result in Non-payment.

When ICD-10 implementation began in October 2015, most payers accepted any diagnosis code in the correct family of codes.

As of October 2016, diagnoses must be coded to the highest level of specificity. This means unspecified codes will be rejected and the claims not paid. If a code does not exist, always use the diagnosis code with ‘other’ rather than ‘unspecified’ in the description.

Deleted & Added Codes to Help with Specificity

Many are applicable to Chiropractic; most deletions and additions were related to cardiology.

  • TMJ – deleted 3 codes (M26.6X), added 12 codes in the new family M26.6XX.
  • Added 20+ codes for cervical disc disorder and degeneration, all in the M50.0XX, M50.1XX, 50.2XX, M50.8XX family.
  • Added sprain of jaw codes, S03.41XX, S03.42XX

Announcing: Consulting Services Now Available!

Does your office currently handle your own billing, but still have a few questions?

Let our team help yours!

In Charge is now offering consulting services in addition to our full service billing. From coding, to contract questions, to claims denials and everything in between, our team of experienced billers is here for you.

For more information, send requests to

Medicare Changes – Overdue?

Medicare has some big changes in the coming two years – here are two big ones to keep an eye on and prepare for:

The End of Social Security Numbers as ID

Thanks to the Medicare Access and CHIP Re-authorization Act of 2015, they will be phasing out the use of Social Security Numbers in the Medicare ID#. You are likely familiar with the current use of the patient social security with a letter at the end (usually “A”). Starting in April of 2018, they will be issuing new “Medicare Beneficiary Identifier (MBI)” to their beneficiary. How will this look?

  • MBI will be 11 characters and made up of numbers and uppercase letters.
  • There will be a transition period from 4/1/18 to 12/31/19 where you can use either HICN or MBI.

Keep an eye out for any delays issued from CMS, but currently, the transition is set to begin on 4/1/18. With HIPAA such a focus for healthcare, it seems overdue to keep a patient’s social security number as secure as possible.

The End of PQRS

For a refresher on what PQRS is, you can read our blog post here. Don’t study too much though, because it is going away! It ends December 31, 2016 and is replaced with Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). This represents a shift from Fee-For-Service payments to “Value-Based” Payments.

  • Most practitioners will fall under the MIPs model rather than the APMs model.
  • The base Fee Schedule will raise by 0.5% per year through 2019, and beginning in 2019 you are eligible to receive positive or negative adjustments to that fee schedule based on your MIPs performance.
  • Contains broader exemptions for smaller providers. If your Medicare billing charges are less than $30,000/year and you see less than 100 Medicare patients/year, you will not be subject to MIPS. NOTE: Many of the published information on the MIPs exclusion for small providers show $10,000 yearly limit, however this has been amended to $30,000 after feedback.
  • First year providers do not participate.
  • As with PQRS, payment adjustments are reflected 2 years after initial data collection/reporting. Initial reporting in 2017 will be due/analyzed in 2018, and payment adjustments based on that data will show in 2019. This also means if you participated in PQRS through 2016, you should still receive your 2% incentive in 2017 and 2018.

There are great resources available for CMS here, and an informative visual guide here from CMS.

If you are a client of In Charge Office Solutions and are interested in participating, we can guide you where to find the 2017 measures that may be available for you to report on. Delaying even one year will result in no increase in payment until 2020, so it is best to start in 2017 if you are participating.

PQRS: It Doesn’t Have to be Painful

There are a few topics that consistently return the most questions in my Continuing Education classes, and one of them is PQRS (Physician Quality Reporting System).  Mainly, why do we have to do this and why are they reducing my Medicare payments if I do not?

What is PQRS?

The Physician Quality Reporting System (PQRS) is a voluntary Centers for Medicare & Medicaid (CMS) program, with the stated purpose of “encouraging health care professionals and group practices to report information on health care practices.” Their goal through this is to lead to better care for Medicare patients.

As a provider, you participate either through Individual or Group Measures. There are hundreds of available measures (download from CMS as an Excel spreadsheet here), and you can chose applicable measures for your office. One of the most widely applicable measures is Medication Documented (Measure #130). There are also measures for Pain Assessment and Follow Up (Measure #131), Functional Outcome Assessments (Measure #182), and many more.

Why Participate?

CMS hopes that participating in these quality measures will lead to better patient care, and more informed care for the patient. On top of that, as an added “incentive” to participate, CMS imposed a 2% fee schedule reduction for providers who do not participate in the program. If you do not participate, you likely already see this on your Medicare Remittance Advices:



If your Medicare patient volume is high enough, it could cause a noticeable decrease in reimbursement. It is a technically voluntary program, so you can decide whether or not your practice should participate based on the administrative load it would require and the decrease in payments you face for not participating.

How to Participate?

Many Electronic Health Record (EHR) programs compile the PQRS relevant information from the patient’s chart and send on for you. This is the most efficient way to participate, and should take the least administrative time for the office. They may also suggest some measures you did not realize your practice would be eligible to report.

If you are not using a full EHR program or if your EHR system does not have PQRS capability, you can report the measures on claims. The measures can be reported using dedicated “G” codes. Each applicable “G” code is added as a line item to your claims. These codes hold no value with Medicare and no reimbursement for them will be made.

Another option is to use a PQRS program. There are many PQRS alternatives to EHR that you can purchase. You must enter all of the information into their system, but they compile it for you and send it on to CMS on your behalf. They can also identify deficiencies and suggest new measures if applicable.

How Many Measures?

CMS suggests each practice report 9 individual measures.  If there are not 9 applicable measures to your practice you can, however, still avoid the reduction. A good example of this is with Chiropractic practices. Reporting on 2-3 measures for a Chiropractic office is usually enough to avoid your 2% reduction in fee schedule.


If any of our clients need PQRS guidance, email to find out if you’re already reporting or how to get started.


You spoke, and we listened! We are excited to announce a new upload feature on our website, and hope you find it easy to use and convenient.

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Auth Requests/photos … & more!

What you have been uploading to us via our desktop program, fax, or email can now simply be uploaded through this website, on our “File Upload” page! Direct link:

Our desktop program will be phased out and this system utilized in its place, however if you prefer faxing that is also an option.

Please contact Emma with any feedback or questions on this process.

Chiropractors: Get Some C.E. Early This Year!

Get your continuing education started early in 2016, and learn how to navigate insurance company contracts, medical policies, claims processing and of course ICD-10 diagnosis coding. Class is combined with Ethics & Law presented by Wayne Coleman, DC, and you still have time to register!

Click the below link, and we hope to see you there!

Martin Luther King Jr. Day 2016


We are not physically in the office today on this Martin Luther King Jr. Day, but you can still reach us by phone or email. (925)398-8635 or

Morning Inspiration

A little office decor at In Charge Office Solutions. Feels good walking in every morning to our motto. We work hard and take pride in it!

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