Orthopedic Coding Alert

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.

"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. When Are IMECodes Required? The following IME codes apply to work-related or medical disability evaluation services: 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 future medical treatment plan; and completion of necessary documentation/certificates and report. 99456 Work-related or medical disability examination by other than 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 future medical treatment plan; and completion of necessary documentation/certificates and report. 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.

"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 [...]