| r's Compensation | | | | Block 11-11a: Leave blank. |
| 1. Worker’s Compensation laws are designed | | | | Block 11b: Enter employer’s name. |
| to ensure that employees who are injured or disabled | | | | Block 11c: Enter the workers compensation insurance |
| on the job are provided with wage replacement and | | | | carrier. |
| medical and rehabilitation benefits. | | | | Block 11d: Leave blank. |
| 2. The intent of most workers compensation acts is to | | | | Block 12: Leave blank. The patient’s signature is |
| establish a system under which a worker no longer | | | | not required for workers compensation claims. |
| has to prove negligence on the part of the employer. | | | | Block 13: Leave blank. |
| Workers compensation act to compensate a worker | | | | Block 14: Enter the date the symptoms started or the |
| for any injury suffered on the job, regardless of fault. | | | | injury occurred. |
| 3. State compensation acts do not cover all | | | | Block 15: Enter the date, if available or applicable. |
| employees or employers. | | | | Block 16: Enter the dates as directed. |
| Federal Worker's Compensation Programs | | | | Block 17: Enter the name and title of any referring |
| 1. Until 1908, workers injured on the job simply lost their | | | | health care provider, if applicable. |
| jobs. Employees bore the full responsibility for | | | | Block17a: Leave blank or enter the referring health |
| on-the-job safety, and employers expressed little if any | | | | care provider’s social security number with no |
| concern for the health or well-being of their workforce. | | | | spaces or hyphens. |
| 2. Federal Employees Compensation Act [FECA] | | | | Block 18: Enter the hospitalization dates, if applicable. |
| provides benefits for work related injuries to all federal | | | | Block 19: Leave blank. |
| employees. | | | | Block 20: Check the appropriate box |
| 3. Occupational Safety and Health Administration Act | | | | Block 21: Enter up to four ICD-9-CM diagnostic codes |
| [OSHA] protect the employees from injuries resulting | | | | in order of priority. |
| from occupational hazards. The act established the | | | | Block 22: Leave blank. |
| federal occupational safety and health administration | | | | Block 23: Enter any assigned managed care |
| and also allowed the states to create an OSHA plan. | | | | preauthorization number. |
| Once the federal government approves the plan, the | | | | Block 24A: Enter the month, day and year [MM/DD |
| state assumes responsibility for carrying out OSHA | | | | YYYY] in the from column. Do not enter to date |
| policies. | | | | unless the insurance carrier requests it. |
| To qualify for workers compensation benefits, the | | | | Block 24B: Enter the place of service code. |
| employee must: | | | | Block 24C: Enter the type of service code. |
| 1. Be injured while working within the scope of the | | | | Block 24D: Enter CPT codes or HCPCS codes as |
| employment agreement or job description. | | | | applicable. Separate modifiers with a space, not a |
| 2. Be injured while performing a service required by the | | | | hyphen. |
| employer. | | | | Block 24E: Enter the diagnosis reference code from |
| 3. Develop a disorder that can be directly linked to | | | | block 21 that best proves the medical necessity for |
| employment like asbestosis, mercury poisoning, or | | | | each service listed in block 24E. |
| black lung diseases. | | | | Block 24F: Enter the fee. |
| Compensation for permanent disability depends on the | | | | Block 24G: Enter the days or units for each line item. |
| following: | | | | This block should be used for multiple visits for identical |
| 1. Severity of the injury. | | | | services, number of miles, units of supplies or oxygen |
| 2. Amount of permanent loss of function. | | | | volume. If anesthesia service, enter the beginning and |
| 3. Age of the employee. | | | | end time of administration. |
| 4. Occupation before the injury. | | | | Block 24H: Leave blank. |
| 5. Rehabilitation potential. | | | | Block 24I: Place an X in this block if the service was |
| Block 1: Check the FECA box for all work-related | | | | provided in a hospital emergency room. |
| injury claims. | | | | Block 24J-24K: Leave blank. |
| Block 1a: first claim: Enter the patient’s social | | | | Block 25: Enter the providers employer federal tax ID |
| security number. Subsequent claims: Enter the | | | | number [EIN]. If there isn’t one, enter the |
| insurance carriers assigned claim number or the | | | | provider’s social security number. |
| patient’s social security number. | | | | Block 26: Enter the patient’s account number, if |
| Block 2: Enter the patients name as directed. | | | | one is assigned by the provider. |
| Block 3: Enter the patients birth date[MM/DD/YYYY] | | | | Block 27: Leave blank. |
| and check the appropriate box for gender. | | | | Block 28: Enter the total charges. |
| Block 4: Leave blank. | | | | Block 29-30: Leave blank. |
| Block 5: Enter the patient’s home address and | | | | Block 31: Providers signature or SIGNATURE ON FILE |
| phone number. | | | | and date. |
| Block 6: Check other. | | | | Block 32: Enter the name, address, city, state, and zip |
| Block 7: Enter employers address and phone number. | | | | code of the place services were provided, if other |
| If known. | | | | than the provider’s office or patient’s |
| Block 8: Check employed. | | | | home. |
| Block 9-9d: Leave blank | | | | Block 33: Enter the name, complete address, and |
| Block 10-10c: Check yes in block 10a. check 10b and | | | | telephone number of the provider’s location. |
| 10c as appropriate. | | | | PIN# and GRP#: leave blank. |
| Block 10d: Leave blank. | | | | |