What are the essential requirements for Texas workers' comp medical billing?
Medical billing for Texas work-related injuries is regulated by the Texas Division of Workers' Compensation (DWC). Claims must be submitted within 95 days of the date of service on a CMS-1500 or electronic 837P, accompanied by complete medical documentation and the DWC Form-073 (Work Status Report). Reimbursement is calculated using the DWC Medical Fee Guideline, which applies a statutory conversion factor to Medicare RBRVS relative value units. Mandatory preauthorization is enforced for non-emergency surgeries, repeat diagnostics, physical therapy beyond initial evaluations, and chronic pain management.
1. The Texas Workers' Compensation Regulatory Structure
Unlike many states, Texas does not mandate that private employers carry workers' compensation insurance. Employers that do not subscribe are called 'non-subscribers', while those that do fall under Texas Labor Code Chapter 408.
For subscribing employers, healthcare providers must follow strict procedural codes and diagnostic requirements established by the DWC.
2. The Texas DWC Mandatory Preauthorization List
Services that forfeit payment if performed without prior approval
Under 28 Texas Administrative Code (TAC) Section 134.600, preauthorization is mandatory for:
• Inpatient hospital admissions and outpatient surgical center procedures.
• Spine surgery and discography.
• Physical and occupational therapy visits (typically requiring re-authorization every 6 to 12 sessions).
• Any investigational or experimental service, durable medical equipment (DME) over $500, and work-hardening programs.