# Work comp evals



## Lanter (Oct 4, 2011)

I do physcial therapy and am finding it hard to fight some of the denials Work Comp ins. companies are sending me.  If a patient is seen for more than one body part at two different times should we not get to bill for an eval for each?  example patient has a major accident and sprains shoulder but fractures the leg, one injury one claim however we start physical therapy on the shoulder right away but the leg has a cast so no treatment or eval at this time for the leg.  3 weeks later cast comes off and  PCP sends to physical therapy to now eval the leg and do treatment.  I am having WC deny claims saying only 1 WC eval per life of the claim but these are done at two different times and with two body parts.  Does anyone else have this issue and can WC deny the eval?  Does this happen with any other type of facility other than Physcial Therapy?


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## tcowboys07 (Oct 4, 2011)

You likely need to append a modifier to the E&M service.

Unrelated E/M service during a post-op period – Use with E/M codes only to indicate that the E/M performed during a postoperative period for a reason(s) unrelated to the original procedure. Modifier 24 applies to unrelated E/M services for either a MAJOR or MINOR surgical procedure.- Failure to use modifier when appropriate may result in denial of the E/M service

Separately identifiable service on same day as procedure – Use with E/M codes only to indicate that the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre- and postoperative care for the procedure performed- Failure to use modifier when appropriate may result in denial of the E/M service


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## ppt (Oct 5, 2011)

you can use modifier 59 for the PT eval code.


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## BerthaTorres (Oct 5, 2011)

Lanter said:


> I do physcial therapy and am finding it hard to fight some of the denials Work Comp ins. companies are sending me.  If a patient is seen for more than one body part at two different times should we not get to bill for an eval for each?  example patient has a major accident and sprains shoulder but fractures the leg, one injury one claim however we start physical therapy on the shoulder right away but the leg has a cast so no treatment or eval at this time for the leg.  3 weeks later cast comes off and  PCP sends to physical therapy to now eval the leg and do treatment.  I am having WC deny claims saying only 1 WC eval per life of the claim but these are done at two different times and with two body parts.  Does anyone else have this issue and can WC deny the eval?  Does this happen with any other type of facility other than Physcial Therapy?



per the OMFS you are allowed one initial PT eval code per claim, if the patient has 2 different injuries with separate date of injuries you can bill for another initial, however if the patient's injuries have the same DOI and claim number you are only allowed 1 initial PT evaluation, and you can bill a re-eval every 30 days.


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## Lanter (Oct 25, 2011)

Who and what is the OMFS and where can I find it?  My employer needs this in writing.

Thanks


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## mitchellde (Oct 25, 2011)

For whatever state you are in you need to look up the provider manual for workers comp.  WC is different in every state, and they do not fall under HIPAA.  However most that I have worked with agree that for a single incident/authorization/claim number, you may have only one initial evaluation, the leg would be a re eval for the same set of injuries, just  a different phase.
OMFS - Official Medical Fee Schedule


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## scyr (Oct 26, 2011)

Hi-  I do WC billing for PT/OT charges.  If the IE's are billed on the same day for 2 different body parts, then we use the -59 modifier.  If they are done on separate days, we have little trouble getting them paid.  An appeal sometimes needs to be done explaining why 2 were done.  I know that the US Dept of Labor will only cover 1 IE under the same case #.  Is there a particular ins that you are having trouble with?


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## Lanter (Nov 16, 2011)

Align and chartis are two but it seems most all deny it.  I am having problem finding it in writing.  My boss wants proof that this is what they are allowed to do.  I think I understand that they only pay 1 time per claim # but I just need to find where it is in writing so I can send to him because we keep appealing and getting no where.  

Thanks for all the responses so far I appreciate the help !


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