Orthopedic Coding Alert

Orthopedic practices are often requested to perform independent medical evaluations (IME), impairment ratings for workers compensation, and liability assessments for insurance companies. These services can pay well, providing billing offices and coders understand how these evaluation services are reimbursed.

According to Dawn R. Carpenter, CPC, billing manager for Orthopedic Associates of Grand Rapids, MI, the request for an orthopedic IME can come from a number of sources seeking an independent or unbiased evaluation. Some examples are, an attorney may want an orthopedic evaluation of a patient who is claiming damages for a fall, an insurance company may want an independent evaluation of a patient who was injured in an auto accident, a corporation may want an evaluation of a potential employees physical ability to do a strenuous job; a workers compensation carrier may need an impairment rating for a back-injury patient.

Typically, these patients will not belong to your practice, and the request for the IME will come for some person or organization other than the patient. Therefore, reimbursement will usually be the responsibility of whoever is requesting the service. Thus you will not be coding and billing these services to the patient or the patients insurance. However, to insure maximum reimbursement for IMEs, an orthopedic practice should be aware of the following tips.

1. Establish Rates Before the Request. Because these services are not part of the usual coding and billing scenario, Carpenter says, you can set your fee at the level you want. These services are time intensive and do not lead to repeat business, so she recommends orthopedic practices evaluate the value of their time and make charges reflect that value. Carpenters practice has established a set one-hour fee that includes an exam, the evaluation and any necessary ratings. The one-hour rate also includes a comprehensive written report. Any additional time, tests, court visits or depositions bring additional charges. All these charges should be established by the practice and then explained in writing and acknowledged by the payer prior to setting an appointment.

The one exception is workers compensation evaluations. Carpenter says, In Michigan, establishing the medical aspects (impairment rating or injury evaluation) of a workers comp case are regulated. Our state regulation manual demands that we use CPT codes 99271-99275 (confirmatory consultations) in reporting these evaluation services and has a set fee that it will pay. Coders should check the regulations for their specific state.

2. Collect or Arrange Payment Prior to Visit. When an IME appointment is being made, the orthopedic practice should arrange for payment in advance. The reason for this is twofold. First, the payer may not be reliable and prepayment avoids repeat billings and collection. Secondly, the payer may not find the evaluation to his or her liking and may try to protest by slowing down or avoiding payment. Carpenter says many requesters of this service are accustomed to prepayment for these services except for workers compensation. Arrangements other than prepayment should be made cautiously with known organizations or individuals who clearly understand the cost of the service.

3. Clarify and Enforce a No Show Policy. Many of these patients dont want to be here, says Carpenter. Were not their physicians, and many of these people are being ordered to have the evaluation done. A significant number wont show up. Therefore, she recommends that practices establish a firm no show policy that charges the full one-hour fee when the patient fails to show up (another reason to collect prior to the visit). This policy should be clearly spelled out and sent in writing to the payer when the appointment is made.

4. Using Billing Codes. When IME services are paid by the requesting party (the attorney, insurance company or employer), Carpenter says her practice uses an internal code that identifies the service for their own internal record keeping. Should an orthopedic practice need to bill for medical evaluation services, the CPT does provide some specific codes (99450-99456) for this service. The CPT states that these codes are used to report evaluations performed to establish baseline information prior to life or disability insurance certificates being issued.

According to the CPT, these codes can be used for new or established patients but do not include any active management of problems undertaken during the encounter. However, if other evaluation and management services or procedures are performed during the same date, you are permitted to report those services in addition to these codes using a 25 modifier. The CPT codes for special evaluation and management services are:

99450 - Basic life and/or disability examination that includes: measurement of height, weight and blood pressure; completion of a medical history following a life insurance pro forma; collection of blood sample and/or urinalysis complying with chain of custody protocols; and completion of necessary documentation/certificates.

99455 - Work-related or medical disability examination by the treating physician that includes: completion of a medical history commensurate with the patients condition; performance of an examination commensurate with the patients 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 patients condition; performance of an examination commensurate with the patients 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.

5. Separate Record Keeping. A final note of caution is that record keeping for IME patients may require something other than the usual. Were not allowed to keep demographic data on IME patients, says Carpenter. When IME patients come in, they are properly identified by name and picture identification, such as a drivers license, but the in-depth personal, medical and financial information normally obtained on new patients is not collected. The records for these patients go to whoever is paying for the services. Carpenter says if (for some reason) a record of an IME patient is kept, the IME record should be kept secure and separate from any other treatment the patient may have at that practice later on. For workers compensation, be sure to check with your states laws and statutes for medical record guidelines to ensure your practice is in compliance.