Hamberger & Weiss LLP


Board Announces Initiative to Replace C-4 Family of Forms with CMS-1500

The Board announced earlier this month that it will replace the C–4 family of forms (with the exception of the C-4.3 permanency evaluation form) with the CMS–1500 formBoard Subject Number 046-1079 describes technical specifications for the rollout and states that it will occur in 3 phases, the first of which will commence on 1/1/19. On that date, providers may begin voluntary transmission of CMS –1500 bills through an approved Board electronic clearinghouse and payers will also be expected to accept electronic receipt of same. On or about 1/1/20, the Board will require use of the electronic CMS–1500 billing form through its clearinghouse. Because the CMS-1500 form does not have the space on it for providers to write a history, opinion on causal relationship, or opinion on degree of disability, the Board will require providers to attach a narrative that includes this detail. The Board has provided a website outlining the CMS–1500 initiative which discusses the requirements it expects providers to adhere to in compiling narratives to attach to their billing forms in order to assist in the management and adjudication of claims.

In addition to the expected requirements of a history of the injury, a diagnosis, and an opinion on causal relationship, the Board also demands detail from the health provider concerning the specific functional work activities or activities of daily living that the patient cannot perform as a result of the injury or illness. This is another example of the Board’s continued emphasis on function as a significant factor in assessing impairment. We hope that the Board will enforce these requirements by supporting payer bill denials for inadequate narrative descriptions. We recommend that our clients carefully review the narrative submissions from providers and deny those bills with narratives that fail to adhere to the standard when the program goes live next year.

Providers can no longer simply “check the box” in order to provide an opinion on causal relationship. In addition to stating whether the incident described by the patient was the competent medical cause of the injury or illness, the provider must also indicate whether the complaints are consistent with the history provided and whether the history is consistent with the objective findings noted on examination. Of note, the Board’s recently revised C-4.3 Form will not be eliminated by the CMS-1500 initiative. Providers will still be expected to fully complete the C-4.3 Form to render a valid opinion on permanency.

There is a potential loophole for providers that wish to avoid the Board’s narrative attachment requirements. The CMS-1500 requirements website states that physicians can include page 2 of the Doctor’s Progress Report (Form C-4.2) “as an optional attachment with the CMS-1500 and medical narrative to provide concise information on the Doctor's Opinion and Return to Work.” It is unclear to us whether this means page 2 of the Form C-4.2 can be submitted in lieu of the required narrative or in addition to the required narrative. If it is the former, then physicians can avoid many of the new narrative requirements by simply attaching the form.

Given prior complaints from providers concerning the Board's suite of medical forms, it is unsurprising that the Board is moving forward with this initiative. In 2010, the Board went so far as to declare a provider shortage in the greater Rochester area, noted the burden on providers created by the Board’s forms requirement, and at that time authorized use of the CMS–1500 form with an attached narrative in lieu of completion of the required C-4 family of forms.

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