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.