Orthopedists who evaluate workers'compensation patients should report the 99455-99456 series only if another party asks them to serve as an "independent medical examiner" (IME). If a patient requests that you evaluate his work-related injuries, you should stick to the standard outpatient E/M codes (99201-99215). Because the "Work-Related or Medical Disability Evaluation Services" codes (99455-99456) reimburse higher than standard E/M codes, some orthopedists assign them to every service involving a workers'compensation patient. This is not correct coding, and if you report these codes carelessly, you might see your workers'compensa-tion referrals dry up very quickly. Link Workers' Comp Evaluation to 'Sick' DX Suppose a workers' compensation patient presents to your practice with a sore back following a shipping-dock accident. You evaluate the patient, order x-rays and diagnose a fractured vertebra (805.0-806.9). You give the patient a copy of the superbill, and he leaves. When Are IMECodes Required? The following IME codes apply to work-related or medical disability evaluation services:
Your practice might receive its IME referrals from a variety of sources that seek independent or unbiased evaluations. Some examples include an attorney whose client seeks damages from an industrial fall, an insurance company seeking an evaluation of an auto accident patient, a corporation that wants to evaluate a patient's disability impairment, or a workers'compensa-tion carrier seeking an impairment rating for a back-injury patient. Medicare does not reimburse for these codes, but most workers'compensation and some private insurers do, so you should set up a payment policy with the requesting party before you perform the exam. Append -25 for Additional Evaluations Suppose the patient presents for a work-related back injury, but during the evaluation the orthopedist discovers that the patient also has Achilles tendon bursitis (726.71)? "The 99455 series does not include any active management," Falbo says. 99450 Covers Baseline Evaluations Some practices believe that CPT's heading for 99450 (Basic life and/or disability examination ), "Basic Life and/or Disability Evaluation Services," means that they can interchange this code for the medical disability evaluation codes 99455-99456, but this is not the case. You should report 99450 if you evaluate a patient to establish baseline information before life or disability insurance certificates are issued, but you should not report this code if you evaluate a work-related injury. Because patients usually present to general practitioners for baseline medical examinations, orthopedists will probably report 99455-99456 more often than they report 99450.
"You should report the appropriate E/M code (99201-99205 for a new patient, 99211-99215 for an established patient) with the appropriate 'sick'diagnosis code," (the fractured vertebra code), says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa.
"State guidelines vary so much that I think it would be wise for practices to contact their state industrial commissions to get their state's opinion of how to properly code work-related injuries," says Elisabeth Fulton, CPC, coding specialist at Orthopaedic Specialists of the Carolinas, a practice with three physiatrists and 14 orthopedists in Winston-Salem, N.C.
If you evaluate a separate condition, you should report the IME code to the requesting party with the back-injury diagnosis code, and you should bill the appropriate E/M code (99201-99215) with 726.71 to the patient's health insurer. 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 and submit a note to the health insurer to let it know that you discovered the bursitis during the course of a separately reported IME.
"For example," Falbo says, "a patient makes an appointment to see his physician for a physical examination required to qualify for a new life insurance policy. The physician completes the required documentation noted above. If this is the only service, he or she should report 99450 with the diagnosis code V70.3 (Other medical examination for administrative purposes)."
As with 99455-99456, you should append modifier -25 to the appropriate E/M code if you perform an unrelated evaluation on the same day that you perform the life/disability evaluation.