Primary Care Coding Alert

Question: We have a patient who is a pilot, and per Federal Aviation Administration (FAA) guidelines, he is periodically required to undergo an exam to evaluate his physical ability to fly. The patient’s insurance company notified us that they will cover such work-related exams providing they are billed using CPT^® code 99455. However, the code’s descriptor states that it is to be used for a “work related or medical disability examination.”

My questions are these: first, does the “or” in the descriptor mean that the code can be used for a work-related disability or a general medical disability, or does it mean that the exam can be work related or disability related? Second, if the code is acceptable for a work-related exam, do we have to match all the bullet points required by the code to be able to bill it? And, last, if we can’t match all the points, whose guidelines do we follow, CPT^®’s or the payers?

Codify Subscriber

Answer: The main issue here really lies in the answer to your second question. The bullet points associated with 99455 (Work related or medical disability examination by the treating physician …) and its companion 99456 (Work related or medical disability examination by other than the treating physician …) are as follows:

• 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.

Of these bullets, two of them ⎯ the “formulation of a diagnosis” or the “development of [a] future medical treatment plan” ⎯ would not be a part of an occupational physical. Consequently, if you are following CPT^® guidelines to the letter, your provider could not fulfill all the requirements of a 99455 or 99456 service for a physical of this nature. The word “and” after the fourth bullet makes clear that all elements are required.

In fact, these codes are applicable to work-related disability and general medical disability exams. Or, to put it another way, these particular exams are “performed to establish baseline information prior to ... disability insurance certificates being issued” per the notes accompanying them. This means the “or” in the codes’ descriptors makes them applicable to work-related disability and medical disability exams, not occupational physicals.

However, private payers are not obligated by law to follow CPT^® guidelines, and for some reason, the payer you are dealing with has decided not to go with codes such as the annual preventive medicine visit codes 99381-99397 (Initial comprehensive preventive medicine evaluation and management of an individual ...) or 99499 (Unlisted evaluation and management service), which are more usually associated with occupational physicals.

So, you will need to discuss with your payer what components of 99455 are required for reimbursement, especially since your provider will not be formulating a diagnosis or a treatment plan during the physical.