Chapter 2: Information for All Providers

Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims

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Effective July 1, 2013

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Look for possible updates and corrections to these payment policies


Table of contents


General information:
All payment policies and fee schedules
Becoming a provider
Charting format
Documentation requirements
Provider Bulletins
Recordkeeping requirements
Self insured employers (SIEs)
Submitting claim documents to the State Fund.

Payment policies:
All professional services
Billing codes and modifiers
Billing instructions and forms
Current coverage decisions for medical technologies and procedures
Overview of payment methods
Split Billing

More info:
Related topics



By report (BR):

A code listed in the fee schedule as “BR” doesn’t have an established fee because the service is too unusual, variable, or new. When billing for the code, the provider must provide a report that defines or describes the services or procedures. The insurer will determine an appropriate fee based on the report.
Link: For more information, see WAC 296-20-01002 .

CPT®, HCPCS, and local code modifiers mentioned in this chapter:


Surgical dressings for home use

Bill the appropriate HCPCS code for each dressing item using this modifier –1S for each item. Use this modifier to bill for surgical dressing supplies dispensed for home use.


Unusual services

Procedures with this modifier may be individually reviewed prior to payment. A report is required for this review. Payment varies based on the report submitted.


Assistant surgeon (see below)


Minimum assistant surgeon (see below)


Assistant surgeon (when qualified resident surgeon not available)

Assistant surgeon modifiers.  Physicians who assist the primary physician in surgery should use modifiers –80, –81, or –82 depending on the medical necessity. Payment for procedures with these modifiers is made at the billed charge or twenty percent of the global surgery amount for the procedure, whichever is less. Refer to the assistant surgeon indicator in the Professional Services Fee Schedule to determine if assistant surgeon fees are payable.


Anesthesia services performed personally by anesthesiologist


Upper left eyelid

General information: All payment policies and fee schedules

Effective date of these policies and fee schedules

This edition of the Medical Aid Rules and Fee Schedules (MARFS) is effective for services performed on or after July 1, 2013.

Who these rules, decisions, and policies apply to and when


All providers must follow the administrative rules, medical coverage decisions, and payment policies contained within the MARFS and Provider Bulletins.

Conflicting policies in CPT® or HCPCS

If there are any services, procedures or text contained in the physicians’ Current Procedural Terminology (CPT®) and federal Healthcare Common Procedure Coding System (HCPCS) coding books that are in conflict with MARFS, the Department of Labor and Industries’ (L&I) rules and policies take precedence.

Link: For more information, see WAC 296-20-010.


All policies in this manual apply to claimants receiving benefits from the State Fund, the Crime Victims Compensation Program, and self-insurers unless otherwise noted.

Links: For more information on L&I WACs, go to

For more information on the Revised Code of Washington (RCW), go to

Questions may be directed to the:

  • Provider Hotline at 1-800-848-0811, or
  • Crime Victims Compensation Program at 1-800-762-3716.

Updates and corrections

An annual update of the entire payment policies and fee schedules (MARFS) is published routinely to coincide with the beginning of each state fiscal year (July 1).

MARFS updates and corrections

On occasion, between annual publications, updates and corrections are made to either the policies or the fee schedules. L&I publishes such updates and corrections on their website (see “Links,” below).

Provider Bulletins

For substantially new policies, additional fee schedule and policy information is published throughout the year in L&I’s Provider Bulletins (see more information about Provider Bulletins in “Current Provider Bulletins,” later in this chapter, and “Links,” below).

L&I Medical Provider News email listserv

To receive notices about payment policy and fee schedule updates and corrections, and new Provider Bulletins, you can join the L&I Medical Provider News email listserv. Via email, listserv participants will receive:

  • Updates and changes to the Medical Aid Rules and Fee Schedules,
  • A link to new Provider Bulletins as soon as they are posted, and
  • Notices about courses, seminars, and new information available on L&I’s website.

Links: Find updates and corrections at under “Fee Schedules,” then “Updates & Corrections.”

L&I’s Provider Bulletins are available at

Interested parties may join the L&I Medical Provider News electronic mailing list at

How state agencies develop fee schedules and payment policies

To be as consistent as possible in developing billing and payment requirements for healthcare providers, Washington State government payers coordinate the development of their respective fee schedules and payment policies.  The state government payers are:

  • The Washington State Fund Workers’ Compensation Program (administered by the Department of Labor and Industries, also known as “L&I”), and
  • The State Medicaid Program (administered by the Medical Purchasing Administration within the Health Care Authority), and
  • The Department of Corrections.

These agencies comprise the interagency Reimbursement Steering Committee (RSC). The RSC receives input from the State Agency Technical Advisory Group (TAG) on the development of fee schedules and payment policies. The TAG consists of representatives from almost all major state professional provider associations.

While the basis for most of the agencies’ fee schedules is the same, payment and benefit levels differ because each agency has its own funding source, benefit contracts, rates and conversion factors.

Maximum fees, not minimum fees

L&I establishes maximum fees for services; it doesn’t establish minimum fees.

RCW 51.04.030 (2) states that L&I shall, in consultation with interested persons, establish a fee schedule of maximum charges.  This same RCW stipulates that no service shall be paid at a rate or rates exceeding those specified in such fee schedule.

WAC 296-20-010(2) reaffirms that the fees listed in the fee schedule are maximum fees.

Link: For more information, see RCW 51.04.030 (2) and WAC 296-20-010(2).

Payment review (audits)

All services rendered to workers’ compensation claims are subject to audit by L&I.

Link: For more information, see RCW 51.36.100 and RCW 51.36.110.

Workers' choice of healthcare provider

Note: Also see information about the “New medical provider network” in the “General information: Becoming a provider” section of this chapter (under “Provider credentialing and compliance”)..

Workers are responsible for choosing their healthcare providers. If provider network requirements apply, the worker may choose any network provider.

At the same time, the Revised Code of Washington (RCW) and the Washington Administrative Code (WAC) allow L&I and self-insured employers (collectively known as the insurer) to recommend particular providers or to contract for services:

  • RCW 51.04.030 (2) allows the insurer to recommend to the worker particular healthcare services or providers where specialized or cost effective treatment can be obtained; however,
  • RCW 51.28.020 and RCW 51.36.010 stipulate that workers are to receive proper and necessary medical and surgical care from licensed providers of their choice.

Link: For more information, see RCW 51.04.030 (2), RCW 51.28.020, and RCW 51.36.010.

General information: Becoming a provider

Provider credentialing and compliance

Note: Also see information about the “Workers’ choice of healthcare provider” in the “General information: All payment policies and fee schedules” section of this chapter (above).

New medical provider network

As part of “Workers’ Compensation Reform” laws passed by the 2011 Washington Legislature, L&I has created a statewide workers’ compensation medical provider network. Network requirements apply to care delivered in Washington State.

Note: Network requirements don’t apply to Crime Victim services.

Starting January 1, 2013, the following providers must be enrolled in the network in order to treat injured workers (including those employed by self-insured businesses) beyond the initial visit:

  • Physicians,
  • Osteopathic physicians,
  • Naturopathic physicians,
  • Podiatric physicians,
  • Physician assistants,
  • Chiropractors,
  • Dentists,
  • Advanced registered nurse practitioners, and
  • Optometrists.

Out-of-state providers and other types of providers are currently exempt and may continue to treat injured workers in calendar year 2013 without joining the network.

Links: For more information on the new medical provider network, see:

Treating Washington workers

A provider must have an active L&I provider account number to treat Washington workers and receive payment for medical services. This includes all types of providers, regardless of whether they are one of the types required to join the network. For State Fund claims, this proprietary account number is necessary for L&I to accurately set up its automated billing systems.

The federally issued National Provider Identifier (NPI) registered with L&I can also be used on bills and correspondence submitted to L&I.

Requirements of providers

All L&I providers must comply with all applicable state and/or federal licensing or certification requirements to assure they are qualified to perform services.  This includes state or federal laws pertaining to business and professional licenses as they apply to the specific provider’s practice or business.

Applying for provider account numbers

Providers who aren't required to join the network can apply for L&I provider account numbers by completing the Non-Network Provider Account Application and W-9 form (F248-011-000).

Links: These L&I provider account formsand information on how to apply or make changes to your provider account are available at: or can be requested by contacting:

L&I’s Provider Credentialing and Compliance section at 360-902-5140, or

  • Provider Credentialing and Compliance
  • Department of Labor & Industries
  • PO Box 44261
  • Olympia, WA 98504-4261

L&I’s Provider Hotline at 1-800-848-0811.

More information about the provider account application process is published in: WAC 296-20-12401.

Providers can apply for NPIs at:

Requirements of providers

All L&I providers must comply with all applicable state and/or federal licensing or certification requirements to assure they are qualified to perform services. This includes state or federal laws pertaining to business and professional licenses as they apply to the specific provider’s practice or business.

Billing for services

Once the L&I provider account number is established, and the federally issued NPI is also registered with L&I, either number can be used on bills and correspondence submitted to L&I.

Find a Doctor (FAD) website

Unless you indicate on your application that you don’t wish to be included on FAD, if you have an active L&I provider account number, you may be listed on the searchable, online FAD database. In 2013, L&I launched a new online provider directory to help support the new provider network requirements.

Link: FAD is available at

Keep your provider account up-to-date

To prevent payment delays, keep us informed of your account changes by completing a Provider Accounts Change Form (form F245-365-000).

Link: This form is available at

Also, accurate information helps ensure smooth communication between:

  • You,
  • L&I,
  • Workers, and
  • Employers.

Self insured employer accounts

Note: For information about setting up a provider account to treat self insured workers’ compensation claims, see the “General information: Self insured employers (SIEs)” section of this chapter, below.

Crime Victims Compensation Program accounts

Healthcare providers can use the same L&I provider number to bill for treating State Fund injured workers and crime victims.

Crime Victim providers are exempt from the provider network.

New providers can sign up for both programs at the same time using one provider application.

Links: You can contact the Crime Victims Compensation Program at 1-800-762-3716, or

Crime Victims Compensation Program
Department of Labor and Industries
PO Box 44520
Olympia, WA 98504-4520

Also, provider resources for the Crime Victims Compensation Program are available on L&I’s website at

General information: Charting format

Required format: SOAP-ER

For charting progress and ongoing care, use the standard SOAP (Subjective, Objective, Assessment, and Plan and progress) format (see below).  In workers’ compensation there is a unique need for work status information.  To meet this need, L&I requires that you add ER to the SOAP contents.  Chart notes must document:

E       Employment issues:

  • Has the worker been released or returned to work?
  • When is release anticipated?
  • Is the patient currently working, and if so, at what job?
  • Include a record of the patient’s physical and medical ability to work.
  • Include information regarding any rehabilitation that the worker may need to undergo.

R       Restrictions to recovery:

  • Describe the physical limitations (temporary and permanent) that prevent return to work.
  • What other limitations, including unrelated conditions, are preventing return to work?
  • Are any unrelated condition(s) impeding recovery?
  • Can the worker perform modified work or different duties while recovering (including transitional, part time, or graduated hours)?
  • Is there a need for return to work assistance?

Office notes, chart notes, progress notes, and 60‑day reports should include the SOAP contents:

S       Worker's Subjective complaints:

  • What the worker states about the illness or injury.
  • Those symptoms perceived only by the senses and feelings of the person being examined which can't be independently proven or established.

Link: For more information, refer to WAC 296‑20‑220(j).

O       Objective findings:

  • What is directly observed and noticeable by the medical provider.
  • This includes factual information, for example, physical exam – skin is red and edematous, lab tests – positive for opiates, X-rays – no fracture.
  • Essential elements of the injured worker's medical history, physical examination and test results that support the attending doctor's diagnosis, the treatment plan and the level of impairment.
  • Those findings on examination which are independent of volunatry action and can be seen, felt, or consistently measured by examining physicians.

Link: For more information, refer to WAC 296‑20‑220 (i).

A       Assessment:

  • What conclusions the medical provider makes after evaluating all the subjective and objective information. Conclusions may appear as:
    • A definite diagnosis (dx.),
    • A "Rule/Out" diagnosis (R/O), or
    • Simply as an impression.
  • This can also include the:
    • Etiology (ET), defined as the origin of the diagnosis, and/or
    • Prognosis, defined as being a prediction of the probable course or a likelihood of recovery from a disease and/or injury.

P       Plan and Progress:

What the provider recommends as a plan of treatment. This is a goal directed plan based on the assessment. The goal must state what outcome is expected from the prescribed treatment, and the plan must state how long the treatment will be administered.

Clearly state treatment performed and treatment plan separately. You must document the services you perform to verify the level, type, and extent of services provided to workers.

Link: For more information, refer to WAC 296-20-010(7) and WAC 296-20-01002 (Chart notes).

Add ER to the SOAP contents to document work status information (see above).

General information: Documentation requirements

How improper documentation could impact payment for services

Documentation of services

Providers must maintain documentation in workers’ individual records to verify the level, type, and extent of services provided to workers.

Documentation must include the amount of time spent for each time-based service performed when:

  • Procedures have a timed component in their descriptions, and
  • Time is a determining factor in choosing the appropriate code.

The insurer may deny or reduce a provider’s level of payment for a specific visit or service if the required documentation isn’t provided or the level or type of service doesn’t match the procedure code billed.

Note: No additional amount is payable for documentation required to support billing.

Required signatures

The insurer won’t pay for forms unless they are signed by the provider.

Note: Providers can submit forms with a signature stamp or an electronic signature from the medical provider.

Requirements in addition to CPT®

In addition to the documentation requirements published by the American Medical Association (AMA) in the CPT® book, the insurer has additional reporting and documentation requirements. These requirements are described in the provider specific payment policy chapters of this document (MARFS) and in WAC 296-20-06101.

Note: The insurer may pay separately for specialized reports or forms required for claims management.

Links: For specific documentation requirements, see Appendix C: Documentation Requirements. For more information, see WAC 296-20-06101.

Changes to medical records

Changes to the medical record legally amended prior to bill submission may be considered in determining the validity of the services billed.

Changes made after bill submission won’t be accepted. If a change to the medical record is made after bill submission, only the original record will be considered in determining appropriate payment of services billed to the department.

Late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation or clinical services. A late entry, addendum, or correction to the medical record must:

  • Bear the current date of that entry, and
  • Be signed by the person making the addition or change.

Note: This policy is based on American Health Information Management Association (AHIMA) and Centers for Medicare & Medicaid Services (CMS) guidelines.

Late entries

A late entry may be necessary to supply additional information that was omitted from the original entry or to provide additional documentation to supplement entries previously written. The late entry must:

  • Bear the current date,
  • Be added as soon as possible, and
  • Be written by the provider who performed the original service and only if the provider has total recall of the omitted information.

To document a late entry:

  • Identify the new entry as a “late entry,” and
  • Enter the current date and time – don’t try to give the appearance that the entry was made on a previous date or an earlier time, and
  • Identify or refer to the date and incident for which the late entry is written, and
  • If the late entry is used to document an omission, validate the source of additional documentation as much as possible.


An addendum is used to provide information that wasn’t available at the time of the original entry.

To document an addendum:

  • Identify the entry as an “addendum” and state the reason for the addendum referring back to the original entry, and
  • Document the current date and time, and
  • Identify any sources of information used to support the addendum.


A correction to the medical record requires that these proper error correction procedures are followed:

  • Draw a line through the entry making sure that the inaccurate information is still legible, and
  • Initial and date the entry, and
  • State the reason for the error, and
  • Document the correct information.

Correction of electronic medical records should follow the same principles of tracking the information.

Falsified documentation

Deliberately falsifying medical records is a felony offense and is viewed seriously when encountered. Examples of falsifying records include:

  • Creating new records when records are requested, or
  • Backdating entries, or
  • Postdating entries, or
  • Predating entries, or
  • Writing over, or
  • Adding to existing documentation (except as described in late entries, addendums, and corrections, above).

Links: For more information, see RCW 51.48.290 and RCW 51.48.250.

Documentation requirements when referring worker for care outside of local community

Whenever it is necessary to refer an injured worker for specialty care or for services outside of the local community, include in the medical notes:

  • The medical reason for the referral, and
  • A statement of why it is reasonable or necessary to refer outside of the community.


General information: Provider Bulletins

What are Provider Bulletins?

Provider Bulletins are temporary communications that give official notification of new or revised:

  • Rules,
  • Laws,
  • Coverage decisions,
  • Policies, and/or
  • Programs.

Provider Bulletins are only for information that hasn’t been previously published, and are available on L&I’s website. If a Provider Bulletin isn’t listed on L&I’s website:

  • It is neither current nor available, and
  • Its content has been incorporated into coverage decisions, payment policies, and fee schedules.

Link: Current Provider Bulletins are available at:



General information: Recordkeeping requirements

Which records a provider must keep

As a provider with a signed agreement with L&I, you are the legal custodian of workers’ records. In the records you keep for each worker, you must include:

  • Subjective and objective findings,
  • Records of clinical assessment (diagnoses),
  • Reports,
  • Interpretations of X-rays,
  • Laboratory studies, and
  • Other key clinical information in patient charts.               

How long a provider must keep records

All records

Providers are required to keep all records necessary for L&I to audit the provision of services for a minimum of 5 years.

Link: For more information, see WAC 296-20-02005.


Providers are required to keep all X-rays for a minimum of 10 years.

Link: For more information, see WAC 296-20-121 and WAC 296-23-140.


General information: Self insured employers (SIEs)

How Self Insurance works in Washington

SIEs or their third party administrators (TPA) administer their own claims instead of paying premiums to the State Fund for L&I to administer.

SIEs must authorize treatment and pay bills according to Title 51 RCW and the Medical Aid Rules (WACs) and Fee Schedules of the state of Washington (WAC 296-15-330(1)), including the payment policies described in this manual.

For SIE claims, healthcare providers should send their bills, reports, requests for authorization, and other correspondence directly to the SIE/TPA.

Links: For a list of SIE/TPAs go to

For more information, see Title 51 RCW and WAC 296-15-330(1).

SIE/TPA provider identification numbers

To bill SIE/TPAs for workers’ compensation claims, contact the individual insurer directly for their provider identification number requirements.

Special SIE claim forms

Self Insurance Accident Report (SIF2)

SIEs use the SIF2 to assign the claim number.

Only the SIE and the worker complete the SIF2.

Link: Employers: To order a supply of SIF2s, go to:

Provider’s Initial Report (PIR)

PIR forms are supplied to providers to assist injured workers of SIEs in filing claims.  The PIR is used in the same way the Report of Accident (ROA) form is used for State Fund covered workers.

Only the provider and the worker complete the PIR.

Link: Providers: To order a supply of PIRs, go to

Providers may bill for interest on medical bills for self-insured claims only

Providers may bill interest on proper medical bills on self-insured claims.

Use Local Code 1159M. Use the Self-Insurance Medical Bill Interst Calculator to calculate the correct interst due.

Link: Self-Insurance Medical Bill Interest Calculator:

Disputes between providers and SIEs

The Self-Insurance (SI) Program of L&I regulates the SIEs.

If a dispute arises between a provider and an SIE, the provider may ask the SI program to intervene and help resolve the dispute.  For disputes related to:

  • Treatment authorization or nonpayment of bills, the SI section’s adjudicator assigned to the claim will handle the request.
    • Call the Self-Insurance section's receptionist at 360-902-6901 to be directed to the appropriate adjudicator.
  • Billing codes, fees, and/or payment policies, the SI section’s Medical Compliance Consultant will handle the request.
  • Bill payment disputes, complete and submit, Self-Insurance Medical Provider Billing Dispute form (F207-207-000)

General information: Submitting claim documents to the State Fund

How to submit

The State Fund uses an imaging system to store electronic copies of all documents submitted on workers’ claims. The imaging system can’t read some types of paper and has difficulty passing other types through automated machinery.

Documents faxed to the department are automatically routed to the claim file; paper documents are manually batched and scanned.

Note: Don’t fax bills!  (See more information in the table under “Where to submit,” below.)


When submitting documents:

  • Submit documents on white 8 ½ x 11-inch paper (one side only), and
  • Leave ½ inch at the top of the page blank, and
  • Put the patient’s name and claim number in the upper right hand corner of each page, and
  • If there is no claim number available, substitute the patient’s social security number, and
  • Reference only one worker/patient in a report or letter. and
  • Staple together all documents pertaining to one claim, and
  • Emphasize text using asterisks or underlines, and
  • Include a key to any abbreviations used, and
  • Submit legible information,


When submitting documents:

  • Don’t use colored paper, particularly hot or intense colors, and
  • Don’t  use thick or textured paper, and
  • Don’t  send carbonless paper, and
  • Don’t use any highlighter markings, and
  • Don’t place information within shaded areas, and
  • Don’t use italicized text, and
  • Don’t use paper with black or dark borders, especially on the top border, and
  • Don’t staple documents for different workers/patients together.

Where to submit

Submitting State Fund bills, reports, and correspondence to the correct addresses or fax numbers:

  • Helps L&I process your documents promptly and accurately,
  • Can prevent significant delays in claim management,
  • Can help you avoid repeated requests for information you have already submitted, and
  • Helps L&I pay you promptly.

Note: Attending providers have the ability to send secure messages through the Claim and Account Center at

The following table shows where you may fax or send correspondence and reports.

If you are submitting… Then you can fax to: Or send to this State Fund mailing address:
Report of Industrial Injury or Occupational Disease
(also known as “Accident Report” or “ROA”)
These fax numbers are for ROAs only!
Department of Labor & Industries
PO Box 44299
Olympia, WA 98504-4299
Activity Prescription Forms (APFs),
Reports and chart notes for State Fund Claims, and
Claim related documents other than bills.
360-902-4567 Department of Labor & Industries
PO Box 44291
Olympia, WA 98504-4291 Reports and chart notes
must be submitted separately from bills.
Provider Account information updates 360-902-4484 Department of Labor & Industries
PO Box 44261
Olympia, WA 98504-4261

Bills, including:

  • UB-04 forms,
  • CMS 1500 forms,
  • Retraining & job modification bills,
  • Home nursing bills,
  • Miscellaneous bills,
  • Pharmacy bills,
  • Compound prescription bills, and
  • Requests for adjustment.
Don’t fax bills! Department of Labor & Industries
PO Box 44269
Olympia, WA 98504-4269
State Fund refunds (attach copy of remittance advice) n/a Cashier’s Office
Department of Labor & Industries
PO Box 44835
Olympia, WA 98504-4835


Payment policy: All professional services

Coverage of procedures

Medical coverage decisions

To ensure quality of care and prompt treatment of workers, L&I makes general policy decisions (called “medical coverage decisions”).  Medical coverage decisions include or exclude a specific healthcare service as a covered benefit.

Procedure codes that aren’t covered

Procedure codes listed as “not covered” in the fee schedules aren’t covered for the following reasons:

  1. The treatment isn’t safe or effective, or is controversial, obsolete, investigational, or experimental, or
  2. The procedure or service is generally not used to treat industrial injuries or occupational diseases, or
  3. The procedure or service is payable under another code.

On a case by case basis, the insurer may pay for procedures in the first two categories above. To be paid, the healthcare provider must:

  • Submit a written request, and
  • Obtain approval from the insurer prior to performing any procedure in these categories.

The request must contain:

  • The reason,
  • The potential risks and expected benefits,
  • The relationship to the accepted condition, and
  • Any additional information about the procedure that may be requested by the insurer.

Link: For more information on coverage decisions and covered services, refer to WAC 296-20-01505, WAC 296-20-02700 through 02850 available in WAC 296-20, WAC 296-20-030 through 03002 available in WAC 296-20, and WAC 296-20-1102.

Requirements for billing

Unlisted codes

A covered service or procedure may be provided that doesn’t have a specific code or payment level listed in the fee schedules. When reporting such a service, the appropriate unlisted procedure code may be used and a special report is required as supporting documentation.

Note: No additional payment is made for the supporting documentation.

Links: For more information, refer to WAC 296-20 (including the definition section) and to the fee schedules available at:

Physician Assistants (PAs)

To be paid for services, PAs must:

  • Be certified and have valid individual L&I provider account numbers, and
  • Bill for services using their provider account numbers, and
  • Use billing modifiers outlined in Appendix E: Modifiers That Affect Payment. For example, to bill for Assistant at Surgery, the PA would use modifier –80, –81, or –82 as appropriate.

Link: For more information on billing code modifiers, see: Appendix E: Modifiers That Affect Payment.

Payment limits

Units of service

Payment for billing codes that don’t specify a time increment or unit of measure is limited to one unit per day. For example, only one unit is payable for CPT® code 97022 regardless of how long the therapy lasts.

Physician Assistants (PAs)

Physician assistant services are paid to the supervising physician or employer at a maximum of 90% of the allowed fee.

Link: For more information about physician assistant services and payment, see WAC 296-20-12501 and WAC 296-20-01501.

PAs may sign any documentation required by the department. Consultations and impairment ratings services related to workers’ compensation benefit determinations aren’t payable to physician assistants.

Link: For more information, see RCW 51.28.100 and WAC 296-20-01501.


Payment policy: Billing codes and modifiers

Billing codes used in the fee schedules

L&I’s fee schedules use the federal HCPCS and agency unique local codes (see more information, below).

Code description limits

Due to space limitations, only partial descriptions of HCPCS or CDT codes appear in the fee schedules.

Due to copyright restrictions, there aren’t descriptions for CPT® codes in the fee schedules.

Providers’ responsibility when billing

Providers must bill according to the full text descriptions published in the CDT-3®, CPT®, and HCPCS books. These books can be purchased from private sources.

Link: For more information, refer to WAC 296-20-010(1).

CPT® codes (HCPCS Level I codes)


HCPCS (commonly pronounced “hick picks”), Level I codes are the CPT® codes developed, updated, and copyrighted annually by the American Medical Association (AMA). There are three categories of CPT® codes:

  • CPT® Category I codes are used for professional services and pathology and laboratory tests. These are clinically recognized and generally accepted services, and don’t include newly emerging technologies.  The codes consist of five numbers (for example, 99201), and
  • CPT® Category II codes are optional and used to facilitate data collection for tracking performance measurement. The codes consist of four numbers followed by an F (for example, 0001F), and
  • CPT® Category III codes are temporary and used to identify new and emerging technologies. The codes consist of four numbers followed by a T (for example, 0001T).


HCPCS Level I modifiers are the CPT® modifiers developed, updated, and copyrighted by the AMA. These modifiers are used to indicate that a procedure or service has been altered without changing its definition.

These modifiers consist of two numbers (for example, –22).

Note: L&I doesn’t accept the five digit modifiers.

HCPCS Level II codes and modifiers


HCPCS Level II codes (usually referred to simply as “HCPCS codes”) are updated by the Center for Medicare & Medicaid Services (CMS). HCPCS codes are used to identify:

  • Miscellaneous services,
  • Supplies,
  • Materials,
  • Drugs, and
  • Professional services.

These codes begin with one letter, followed by four numbers (for example, K0007).

Codes beginning with D are developed and copyrighted by the American Dental Association (ADA) and are published in the Current Dental Terminology (CDT-3).


HCPCS Level II modifiers are updated by CMS and are used to indicate that a procedure has been altered.

These modifiers consist of either:

  • Two letters (for example, –AA), or
  • One letter and one number (for example, –E1).

Local codes and modifiers


Local codes are used to identify unique services or supplies.

These codes consist of four numbers followed by one letter (except F and T). For example, 1040M, which must be used to code completion of the Report of Accident and Providers Initial Report forms.

L&I will modify local code use as national codes become available.


Local code modifiers are used to identify modifications to services.

These modifiers consist of one number and one letter (for example, –1S).

L&I will modify local modifier use as national modifiers become available.

Quick reference guide for all billing codes and modifiers

If the billing code type is… Then the purpose of the code is: And the code format is: And the modifier format is: And the source of the code is:
HCPCS Level I: CPT® Category I Professional services, pathology and laboratory tests. 5 numbers 2 numbers AMA/ CMS
HCPCS Level I: CPT® Category II Tracking codes, to help collect data for tracking performance measurement. 4 numbers followed by F n/a AMA/ CMS
HCPCS Level I: CPT® Category III Temporary codes for new and emerging technologies. 4 numbers followed by T n/a AMA/ CMS
HCPCS Level II (HCPCS code) Miscellaneous services, supplies, materials, drugs, and professional services. 1 letter followed by 4 numbers 2 letters, or
1 letter followed by  1 number
Local code (unique to L&I) L&I unique services, materials, and supplies. 4 numbers followed by 1 letter (but not F or T) 1 number followed by 1 letter L&I


Payment policy: Billing instructions and forms

Who to bill (which insurer)

Each insurer uses a unique format for claim numbers.  This will help you identify which insurer to bill for a specific claim:

  • State Fund claims either begin with:
    • The letters B, C, F, G, H, J, K, L, M, N, P, X, or Y followed by six digits, or
    • Double alpha letters (example AA) followed by five digits.
  • Self-insured claims either begin with:
    • S, T, or W followed by six digits, or
    • Double alpha letters (example SA) followed by five digits.

Note: U. S. Department of Energy (DOE) claims are now self-insured.

  • Crime Victims claims either begin with:
    • A V followed by six digits, or
    • Double alpha letters (example VA) followed by five digits.
  • Federal claims begin with A13 or A14.

Link: Questions and billing information about federal claims should be directed to the U.S. Department of Labor at 206-398-8100 or 206-398-8200 or their website at

Medicare claims

If a worker has an allowable workers’ compensation injury or illness, workers’ compensation is always the primary insurance for the injury or illness.

  • Medicare is never a secondary payer for workers’ compensation claims. The workers’ compensation insurer’s payment is the full payment.
  • Medicare can’t be billed for allowed workers’ compensation claims.
  • If Medicare is incorrectly billed for a workers’ compensation claim, the provider is required to reimburse all payments made by Medicare.

Report of Accident (ROA) requirements

Providers now have the option to file ROAs online via FileFast.

ROAs submitted within 5 business days after an injured worker’s date of first treatment is paid at a higher rate than ROAs submitted after 5 business days. The department pays for completion of ROAs (1040M) on a graduated scale based on when they are received by the department following the date of first treatment (box 15b on the paper ROA form).


Within 5 days

6-8 days

9 days or more

Max fee via paper or fax




Max fee via FileFast (additional $10 incentive)




Note: When filling via FileFast make sure the $10 web incentive is added.

Payment adjustments on State Fund claims

Provider should bill usual and customary charges. For ROAs received more than 5 business days from the date of first treatment (box 15b on paper ROA), L&I’s payment system automatically reduces the ROA payment.

Payments are increased for participation in the Centers of Occupational Health and Education (COHE) or for online claim-filing (FileFast).

Payment for completion of the ROA/ Providers Initial Report (PIR)

A provider with a valid provider account number may be paid for completing a ROA or PIR if they are licensed as one of the following:

  • ARNP
  • DC
  • DDS
  • DO
  • DPM
  • MD
  • ND
  • OD
  • PA-C

Billing requirements

  • Bill only 1 ROA or PIR, per claim, using local code 1040M.
  • Submit the ROA or PIR to the insurer immediately following the date of first treatment.
  • Complete the ROA using instructions on form F242-130-000 (English) or F242-130-999 (Spanish).
  • Complete the PIR using instructions on the back of form F207-028-000.  If you need additional space:
    • Attach the information to the application, and
    • Include the claim number at the top of the page.

Note: Reimbursement amount is based on the date the healthcare provider includes in box 15b of the paper ROA (“This Exam Date.”). If that box is blank, the payment system will look at box 16 of the paper ROA (“Signature of the health care provider.”). To ensure correct payment, make sure the ROA is filled out completely.


Billing procedures

Link: Information on billing procedures is outlined in WAC 296-20-125.

Billing manuals and billing instructions

The General Provider Billing Manual (publication F248-100-000) and L&I’s provider specific billing instructions contain:

  • Billing guidelines,
  • Reporting and documentation requirements,
  • Resource lists, and
  • Contact information.

Link: Providers can download these manuals on L&I’s website at or request these publications from L&I’s Provider Accounts section or the Provider Hotline. (For contact information, see the “General information: Becoming a provider” section of this chapter, above.)

Billing workshops

L&I offers providers free billing workshops to help you save time and money by:

  • Learning to bill L&I correctly,
  • Getting new tools for doing business with L&I, and
  • Meeting your Provider Account Representatives.

Link: Additional information on the workshops is available at

Electronic billing for State Fund bills

Electronic billing is available to all providers of services to injured workers covered by the State Fund. Electronic billing is helpful because it:

  • Allows greater control over the payment process,
  • Eliminates entry time,
  • Allows L&I to process payments faster than paper billing,
  • Reduces billing errors, and
  • Decreases the costs of bill processing.

Link: See “Cost Comparison Estimator” at

There are three secure ways providers can bill L&I electronically:

  1. Free online billing form (no specific software/clearinghouse required), or
  2. Upload bills using your software (the department doesn’t supply billing software for electronic billing), or
  3. Use an intermediary/clearinghouse.

Note: Your correspondence and reports may be faxed to L&I.

Links: Fax numbers can be found in the “Submitting claim documents to the State Fund” payment policy section (later in this chapter) or on L&I’s website at

For additional information on electronic billing:

Billing forms

Providers must use L&I’s current billing forms.

Note: Using out of date billing forms may result in delayed payment.

To order new billing forms or other L&I publications:

  • Complete the Medical Forms Request form (F208-063-000), and
  • Send it to L&I’s warehouse (address listed on the form).

Links: The Medical Forms Request form (F208-063-000) can be found:

You may also download other forms from L&I’s website at

When to submit a billing adjustment vs. a new bill to the State Fund

When an entire bill is denied, you need to submit a new bill to be paid for your services.

When part of the bill is paid, you must submit an adjustment for the services that weren’t paid.

Link: Additional information on adjustments is available at

When provider can bill worker for missing scheduled appointment

Workers are expected to attend scheduled appointments.

  • WAC 296-20-010(5) states: L&I or self-insurers won't pay for a missed appointment unless the appointment is for an examination arranged by L&I or the self-insurer,
  • A provider may bill a worker for a missed appointment per WAC 296-20010(6) if the provider:
    • Has a missed appointment policy that applies to all patients regardless of payer, and
    • Routinely notifies all patients of the missed appointment policy.
  • Providers must notify the claim manager immediately when an injured worker misses an appointment.

Note: L&I or self-insurers aren’t responsible or involved in the implementation and/or enforcement of any provider’s missed appointment policy.

Link: For more information, see WAC 296-20-010(5) and (6).

Payment policy: Current coverage decisions for medical technologies and procedures

Coverage decisions for medical technologies and procedures

Link: For more information on these decisions, see the Condition and Treament Index at:


Payment policy: Overview of payment methods

Ambulatory Surgery Center (ASC) payment methods

ASC rate calculations

Insurers use a modified version of the ASC payment system that was developed by the Centers for Medicare and Medicaid Services (CMS) to pay for facility services in an ASC.

Link: For more information on this payment method, see the Ambulatory Surgery Centers (ASCs) chapter or refer to WAC 296-23B.

By report

Insurers pay for some covered services on a by report basis. Fees for by report services may be based on the value of the service as determined by the report.

Note: See definition of by report in “Definitions” at the beginning of this chapter.

Maximum fees

For services covered in ASCs that aren’t priced with other payment methods, L&I establishes maximum fees.

Hospital inpatient payment methods

Link: The following is an overview of the hospital inpatient payment methods. For more information, see the Hospitals chapter or refer to WAC 296-23A.


Self-insurers use Percentage of Allowed Charges (POAC) to pay for all hospital inpatient services.

Link: For more information, see WAC 296-23A-0210.

All Patient Refined Diagnosis Related Groups (APR DRG)

L&I uses All Patient Refined Diagnosis Related Groups (APR DRGs) to pay for most inpatient hospital services.

Link: For more information, see WAC 296-23A-0200.

Per diem

L&I uses statewide average per diem rates for five APR DRG categories:

  • Chemical dependency,
  • Psychiatric,
  • Rehabilitation,
  • Medical, and
  • Surgical.

Hospitals paid using the APR DRG method are paid per diem rates for APR DRGs designated as low volume.

Percent of Allowed Charges (POAC)

L&I uses a POAC payment method:

  • For some hospitals exempt from the APR DRG payment method, and
  • As part of the outlier payment calculation for hospitals paid by the APR DRG.

Hospital outpatient payment methods

Link: The following is an overview of the hospital outpatient services payment methods.  For more information, see the Hospitals chapter or refer to WAC 296-23A.


Self-insurers use the maximum fees in the Professional Services Fee Schedule to pay for:

  • Radiology,
  • Pathology,
  • Laboratory,
  • Physical therapy, and
  • Occupational therapy services.

Self-insurers use POAC to pay for hospital outpatient services that aren’t paid with the Professional Services Fee Schedule.

Link: For more information, see WAC 296-23A-0221.

Ambulatory Payment Classifications (APC)

L&I pays for most hospital outpatient services with the Ambulatory Payment Classifications (APC) payment method.

Link: For more information, see WAC 296-23A-0220.

Professional Services Fee Schedule

L&I pays for most services not paid with the APC payment method according to the maximum fees in the Professional Services Fee Schedule.

Link: The Professional Services Fee Schedule is available at

Percent of Allowed Charges (POAC)

Hospital outpatient services are paid by a POAC payment method when they aren’t paid:

  • With the APC payment method, or
  • The Professional Services Fee Schedule, or
  • By L&I contract.

Out-of-state hospital payment methods

Link: For information on out-of-state hospital outpatient, inpatient, and professional services payment methods, see WAC 296-23A-0230.

Pain management payment methods

Chronic Pain Management Program fee schedule

Insurers pay for Chronic Pain Management Program Services using an all inclusive, phase based, per diem fee schedule.

Professional provider payment methods

Links: The following is an overview of the payment methods for professional provider services. For more information, see the relevant payment policy chapters or refer to WAC 296-20, WAC 296-21, and WAC 296-23.

The Professional Services Fee Schedule is available at

Resource Based Relative Value Scale (RBRVS)

Insurers use the Resource Based Relative Value Scale (RBRVS) to pay for most professional services.

Services priced according to the RBRVS fee schedule have a fee schedule indicator of R in the Professional Services Fee Schedule.

Links: More information about RBRVS is contained in the Washington RBRVS Payment System chapter.

Anesthesia fee schedule

Insurers pay for most anesthesia services using anesthesia base and time units.

Link: For more information, see the Anesthesia Services chapter.

Pharmacy fee schedule

Insurers pay pharmacies for drugs and medications according to the pharmacy fee schedule.

Link: For more information, see the Pharmacy Services chapter.

Drugs paid using Average Wholesale Price (AWP)

L&I’s maximum fees for some covered drugs administered in or dispensed from a prescriber’s office are priced based on a percentage of the AWP of the drug.

Drugs priced with an AWP method have AWP in the “Dollar Value” columns and a D in the fee schedule indicator (“FSI”) column of the Professional Services Fee Schedule.

Links: For more information, see the Pharmacy Services chapter.

For a definition of “Average Wholesale Price” (AWP), see WAC 296-20-01002.

Clinical Laboratory fee schedule

L&I’s clinical laboratory rates are based on a percentage of the clinical laboratory rates established by CMS.

Services priced according to L&I’s clinical laboratory fee schedule have a fee schedule indicator (“FSI”) of L in the Professional Services Fee Schedule.

Flat fees

L&I establishes rates for some services that are priced with other payment methods.

Services priced with flat fees have a fee schedule indicator (“FSI”) of F in the Professional Services Fee Schedule.

State Fund contracts

State Fund pays for utilization management services by contract.

Services paid by contract have a fee schedule indicator (“FSI”) of C in the Professional Services Fee Schedule.

Note: The Crime Victims Compensation Program doesn’t contract for these services.

By report

Insurers pay for some covered services on a by report basis. Fees for by report (BR) services may be based on the value of the service as determined by the report.

Services paid by report have a fee schedule indicator (“FSI”) of N in the Professional Services Fee Schedule and BR in other fee schedules.

Note: See definition of by report in “Definitions” at the beginning of this chapter.

Program only

Insurers pay for some unique services under specific programs.  Example programs include:

  • Centers for Occupational Health Education (COHE), and
  • Orthopedic and Neurological Surgeon Quality Pilot.

Residential facility payment methods

Boarding Homes and Adult Family Homes

Insurers use per diem fees to pay for medical services provided in Boarding Homes and Adult Family Homes.

Nursing Homes, and Transitional Care Units utilizing swing beds for long term care

Insurers use modified Resource Utilization Groups (RUGs) to develop daily per diem rates to pay for Nursing Home Services.

Critical Access Hospitals and Vetereans Hospitals utilizing swing beds for sub acute care or long term care

Insurers use hospital specific POAC rates to pay for sub acute care (swing bed) services.


Payment policy: Split billing - treating two separate conditions

Requirements for billing

If the worker is treated for two separate conditions at the same visit, the charge for the service must be divided equally between the payers.

Links: For more information, see WAC 296-20-06101(10), and the General Provider Billing Manual (publication F248-100-000), and Chapter 10, Evaluation and Management (E/M) Services.

If you’re looking for more information about… Then go here:
Administrative rules for
Ambulatory Surgery Center (ASC)
payment methods
Washington Administrative Code (WAC) 296-23B:
Administrative rules for average
wholesale price (AWP)
WAC 296-20-01002:
Administrative rules for billing procedures WAC 296-20-125:
Administrative rules for charting requirements WAC 296-20-220:
WAC 296-20-01002:
Administrative rules for coverage decisions WAC 296-20-01505:
WAC 296-20-02700 through -02850 available in WAC 296-20:
WAC 296-20-030 through -03002 available in WAC 296-20:
WAC 296-20-1102:
Administrative rules for
documentation requirements
WAC 296-20-06101:
Administrative rules for
hospital payment methods
WAC 296-23A:
Administrative rules for Medical Aid WAC 296-20-010:
Administrative rules for
missed appointments (worker no shows)
WAC 296-20-010(5) and (6):
Administrative rules for
Physician Assistants (PAs)
WAC 296-20-12501:
WAC 296-20-01501:
Administrative rules for provider
credentialing and compliance
WAC 296-20-01010 through WAC 20-01090 available in WAC 296-20: WAC 296-20-12401:
Administrative rules for
recordkeeping requirements
WAC 296-20-121:
WAC 296-20-02005:
WAC 296-23-140:
Becoming an L&I provider L&I’s website:
Billing adjustments L&I’s website:
Billing code modifiers that affect payment Appendix E:
Modifiers That Affect Payment
Billing workshops for providers L&I’s website:
Cost Comparison Estimator for
electronic versus paper billing
L&I’s website:
Crime Victims Compensation Program L&I’s website:
Coverage decisions for medical
technologies and procedures
L&I’s website:
Documentation requirements Appendix C:
Documentation Requirements
Electronic billing L&I’s website:
Fax numbers for sending
to the State Fund
L&I’s website:
Federal injured worker claims U.S. Department of Labor website:
Federally issued National Provider Identifier (NPI) National Plan & Provider Enumeration System (NPPES) website:
Fee schedules for all healthcare and
vocational services
L&I’s website:
Find a Doctor (FAD) website L&I’s website:
General information about WACs and RCWs Info on WACs, on L&I’s website:
Info on RCWs, on Washington State Legislature’s website:
General Provider Billing Manual
(publication F248-100-000)
L&I’s website:
Join the Network L&I’s website:
Legislated laws (from Washington state
Legislature) for documentation requirements
Revised Code of Washington (RCW) 51.48.290:
RCW 51.48.250:
Legislated laws for Medical Aid RCW 51.01.030(2):
RCW 51.04.030(2):
RCW 51.28.020:
RCW 51.36.010:
RCW 51.36.100:
RCW 51.36.110:
Legislated laws for Physician Assistants (PAs) RCW 51.28.100:
L&I’s Claim and Account Center L&I’s website:
L&I Medical Provider News electronic mailing list L&I’s website:
Medical Forms Request (form F208-063-000) L&I’s website:
Payment policies for Ambulatory Surgery Centers (ASCs) Chapter 32:
Ambulatory Surgery Centers (ASCs)
Payment policies for anesthesia services Chapter 4:
Anesthesia Services
Payment policies for hospitals Chapter 35:
Payment policies for pharmacy services Chapter 23:
Pharmacy Services
Payment policies for the Resource
Based Relative Value Scale (RBRVS)
Chapter 31:
Washington RBRVS Payment System
Provider Accounts Change Form
(form F245-365-000)
L&I’s website:
Provider Bulletins L&I’s website:
Provider’s Initial Report form L&I’s website:
Provider Network and COHE Expansion L&I’s website:
Report of Industrial Injury or Occupational
form (also known as “Accident
Report” or “ROA”; form F242-130-000)
L&I’s website:
Self Insurance Accident Report (SIF2) form L&I’s website:
Self insured employer (SIE) or third party
administrator (TPA)
contact information
L&I’s website:

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.

CPT® codes and descriptions only are © 2012 American Medical Association

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