WCIS eNews No. 136
September 11, 2017

Updates and Changes to WCIS California Medical Version 2.0 Effective September 27, 2017

The WCIS regulations adopted on March 27, 2017 pertaining to medical billing data reporting go into effect on September 27, 2017. The WCIS regulations adopted the IAIABC Workers’ Compensation Medical Bill Data Reporting Implementation Guide, Release 2.0 February 1, 2015 Publication. This version of the IAIABC Guide created the 2410 loop for reporting compound drugs and the K3 segment to report original drugs when reporting repackaged drugs. A detailed list of changes made in the California Medical Implementation Guide Version 2.0 is available on the WCIS website. The Technical Requirement table has also been updated to reflect the changes in the California Implementation Guide.

Additional Points of Clarification

Reporting on segment SV402-1
The IAIABC approved Issue Resolution Request (IRR) MED834 adds HCPCS codes and Jurisdiction codes for reporting on SV402-1. Now SV402-1 and SV402-2 can have any one of the following three qualifiers and corresponding code sets respectively:

    1. Qualifier SV402-1 = N4,  SV402-2 = use DN0721 NDC Billed Code
    2. Qualifier SV402-1 = HC,  SV402-2 = use DN0714 HCPCS Line Procedure Billed Code
    3. Qualifier SV402-1 = ER,  SV402-2 = use DN0715 Jurisdiction Procedure Billed Code

Starting September 27, 2017, the WCIS will only accept valid codes from one of the above listed three code sets. The workaround i.e., prefixing a HCPCS code with ‘HC_’ on SV402-2 with a qualifier N4 on SV402-1, allowed to report prescription bills with HCPCS codes prior to the approval of IRR MED834, will no longer be permitted. Use the appropriate qualifier (HC) and code set (HCPCS code) to report such bills.

Reporting DN 0537 Billing Provider Primary Specialty Code.
DN 0537 Billing Provider Primary Specialty Code is now mandatory/conditional. If the billing provider does not have a specialty code, for example, a PBM on a pharmacy bill, make sure the Rendering Billing Provider information for that bill are reported in their respective fields. For more detail, refer to the validation logic in the Technical Requirement for DN 0537.

Reporting Referring Provider information (DN 0690, DN0691 and DN0699) on pharmacy bills.
For pharmacy bills, please note the IAIABC has designated the prescribing provider as the referring provider. Pharmacy bills should include referring provider information.

Reporting DN 0557 Diagnosis Pointer and DN 0522 Diagnosis Code on dental bills.
WCIS now accepts DN 0522 Diagnosis Code and DN0557 Diagnosis Pointer for dental bills. IRR MED804 allowed the use of SV311 for dental bills. This permits reporting of DN0557 Diagnosis Pointer on dental bills.  

Reporting out of Country DN 0050 Employee Mailing Postal Code.
To report DN 0050 Employee Mailing Postal Code outside of the United States, prefix the postal code with the 2-character non-US country code followed by a dash ( - ). For example, postal code ‘V5V 2H3’ in Canada should be reported as ‘CA-V5V 2H3’.

Reporting DN 0715 Jurisdiction Procedure Billed Codes and DN0718 Jurisdiction Modifier Billed code on Dental Bills
WCIS now accepts DN 0715 Jurisdiction Procedure Billed Code and DN DN0718 Jurisdiction Modifier Billed Code on dental bills. IRR MED851 allowed the use of the qualifier ‘ER’ on Segment SV301-1 for dental bills. This permits the reporting of DN0715 Jurisdiction Procedure Billed Code on SV301-2 and DN0718 Jurisdiction Modifier Billed Code on segments SV301-3 to SV301-6.

WCIS trading partner contacts:

Johnny Lee
email: jblee@dir.ca.gov
phone: 510-286-6772
Trading partner letters A, C, G, I-L, S-V, Z

Elisema Cantu
email: ecantu@dir.ca.gov
phone: 510-286-6763
Trading partner letters B, D-F, H, M-R, W-Y

Antoinette Esqueda
email: aesqueda@dir.ca.gov
phone: 510-286-6773
Medical reports technical contact

Contents of this bulletin do not change existing regulatory requirements; they provide additional or revised detail about the technical implementation of those requirements. All technical changes will subsequently be reflected in other WCIS documentation. Any bulletin can be forwarded as needed, but should be forwarded in its entirety and without modification. If you have received a forwarded copy of this bulletin and are concerned about its authenticity, you can view this and previous bulletins on our WCIS web site: www.dwc.ca.gov/wcis.htm.

Format: This WCIS e.News is sent in HTML format, and is best viewed in that format. Consult your e-mail application's help files or your computer support unit for assistance in viewing HTML-formatted e-mail.

Distribution: Subscribe to the WCIS e.News.