Eli's Rehab Report

Physiatrists 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 physiatrists 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 workerscompensation referrals dry up very quickly.

For example, 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 strained lumbar spine (847.2).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 spine strain code), says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa.

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 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.

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 patients disability impairment, or a workerscompensation carrier seeking an impairment rating for a back-injury patient.

Medicare does not reimburse for these codes, but most workerscompensation 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 states 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.

Suppose the patient presents to the physiatrist for a work-related back injury, but during the evaluation the physiatrist discovers that the patient also has Achilles tendon bursitis (726.71)?

"The 99455 series does not include any active management," Falbo says. 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 patients health insurer.

You should 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 99211-99215 series 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.

Some coders believe that CPTs 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.

"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.

Because patients usually present to general practitioners for baseline medical examinations, physiatrists will probably report 99455-99456 more often than they report 99450.