Why was my supplementary payment for the WC196 form denied even though I sent the form to Pinnacol?

Pinnacol is reviewing bills and matching them with the submission of WC196 forms. The WC196 form needs to be completed to be eligible for supplementary payment. The most common reason for denial of the supplemental payment is the WC196 form was incomplete.

Should the WC196 form be sent in with the initial evaluation?

No. The WC196 form was developed to be used as a communication form from the therapist to the referring or authorized treating physician (ATP) for follow-up visits with the physician. However, we do encourage the PT/OT to administer the functional tool at the initial evaluation and first assessment to determine a baseline for subsequent evaluations on return visits.

Do PTs use one of the approved Division tests each time the patient comes in?

Yes. They will administer a test each time they want to re-assess function. They will use the WC196 form to report progress at the prescribed intervals. The WC196 form may be submitted and reimbursed every 2 weeks for the first six weeks and once every four weeks for the duration of the therapy.

If the WC196 form is not used for re-evaluation, then what is it for?

The WC196 form is used as a communication tool between the therapist and the referring provider. At the initial assessment, the physical therapist obtains scores from the functional tool. Two weeks later, the same functional assessment is administered and the WC196 form is completed with the initial and subsequent test results. The WC196 form is sent to the referring provider before the patient’s follow-up appointment with the ATP and is also sent to the insurer so the therapist can be reimbursed for completing the WC196 form.

My therapy documentation contains measurements and functional gains within the body of the note. Can’t the providers use my notes to determine the functional gain?

No, providers report that it is difficult to decipher information contained within the note to determine functional gains. The WC196 form allows for clear and concise information in a consolidated format to the referring provider.

What code should I bill to the payer and how much is reimbursement?

The correct billing code for completing the form and reporting it to the provider is Z0817. It will be reimbursed at $15.61 for 2023 or the contract fee schedule rate when correctly submitted and completed.

Can massage therapists bill the WC196 form?

No, this form is to be completed by PTs and OTs only. Massage therapists are not routinely trained in utilizing functional tools and PTs and OTs are trained and use them regularly.

If a patient has multiple diagnoses, do therapists complete a form for each diagnosis?

Reporting the status and progress for multiple diagnoses can be performed one of two ways:

• The therapist can fill out the WC196 form with the subjective information such as the goals and assessment of improvement with the objective findings for one of the diagnoses and use an additional form to document the objective findings table and assessment for subsequent diagnoses.
• The other option would be to use the objective findings table for the main diagnosis and write the additional information for the other diagnoses in the “other objective findings” section.
  

In either case, the billing code Z0817 will only be billed once.

We’re here to help ensure your billing success. If you have questions or need information, please contact Pinnacol Assurance at billingsuccess@pinnacol.com or 303.361.4940.

Rehabilitation communication form (WC196)

Colorado Division of Workers' Compensation - Fee Schedule (Rule 18)