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Neurology & Pain Management Coding Alert

Select 99455-99456 - Not E/M Codes - for WC Evaluations

Published on Sun Sep 19, 2004

If your physician evaluates a patient for a workers' compensation claim, you should turn to codes 99455-99456 rather than E/M services such as outpatient consults (99241-99245) or office visits (99201-99215).
 
The neurologist most often performs 99455-99456 as a baseline for disability certification or to establish the patient's percentage of disability from injuries or disease. CPT defines the codes as follows:

99455 - Work-related or medical disability examination by the treating physician that includes:
 

  •   completion of a medical history commensurate with the patient's condition
     
  •   performance of an examination commensurate with the patient's condition
     
  •   formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment
     
  •   development of medical treatment plan
     
  •   completion of necessary documentation/certificates and report.


    99456 - Work-related or medical disability examination by other than the treating physician ... .

    But you may report a standard E/M service and a workers' compensation evaluation on the same day, as long as the physician provides E/M services for a condition unrelated to the workers' compensation claim.
     
    "If workers' compensation does not pay all of the charges because only a portion of the services is compensable (i.e., the patient received services for a condition which was not work-related concurrently with services which were work-related), Medicare benefits may be paid to the extent that the services are not covered by any other source which is primary to Medicare," according to Section 2370.2 of the MCM. Commercial payers recognize their contractual obligation to pay benefits for non-worker's-compensation conditions.
     
    Example: An established patient may present for a workers' compensation evaluation following an on-the-job automobile accident. At the same time, the patient has ongoing complaints of lower-back pain. The neurologist evaluates the patient for cervical pain (caused by the accident) and lumbar pain (the ongoing problem not related to workers' compensation).

    In this case, you may report 99455 and an appropriate-level E/M service, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).
     
    To allow for separate payment of the E/M service, you must also append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

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