Forum - Questions & Answers

Dec 3rd, 2013 - blanche22 20 

billing 99455

Can I bill the 99455 with 99214 and do I need a modifier 25 on the 99214?

Dec 3rd, 2013 - agent00711   151 

re: billing 99455

CPT® 99455: Performing an impairment rating be sure to include the following:

-Completion of a medical history commensurate with the patient’s condition:
-Performance of an examination commensurate with the examination 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 / certificated and report.

This code cannot be billed in addition to an E/M service 99201-99205 or 99211-99215 on the same date of service.

Dec 3rd, 2013 - blanche22 20 

re: billing 99455

Are there any documented instructions besides the CPT® Procedure book that I could show the Dr.? He usually doesn't believe me unless I show him in writing that he can't bill this way. Thank you

Dec 3rd, 2013 - agent00711   151 

re: billing 99455

SORRY...the guidance previously posted is relative to GA WC: Here is guidance per Super Coder hope this helps....if following this guidance, append modifier -25 to the E/M.

CPT® Code 99455 Details
Code Descriptor
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.

Lay Term
Clinical Responsibility
The physician examines a patient for reasons related to a work related or medical disability. He or she completes forms, conducts the examination, formulates a diagnosis, creates a medical treatment plan, and completes any necessary documentation or reports. He or she discusses findings and treatment plans with the patient.

Terminology
Workers' compensation: Insurance paid by companies to cover some costs related to an employee's medical care because of illness or injury acquired in the course of their work.

Work related disability: A medical condition or disability caused by something in the patient's work environment (an accident or injury, exposure to potentially harmful materials, etc.)
Tips
Remember "work related" when considering whether to report 99455. The services covered by 99455 deal with work related or medical disability issues.
Only report 99455 for special medical evaluations that include extensive tests for disability status.

The code includes individualized, specialized evaluation and testing -- which goes beyond standard E/M office visit codes.

The physician must itemize the total time spent reviewing the patient's medical records before you can code the service as part of 99455.

Experts recommend that the physician write to notes when handling a case that qualifies for 99455. One note should document services related to the workers' compensation case and the other should support the patient's other diagnoses. Carve out the work related to each service so you can determine the level to bill for each.

If the physician performs an E/M service in addition to a workers' compensation evaluation, you can report the appropriate E/M office visit code in addition to 99455.

Clinical Scenario:
Question: I have a patient who is applying for early disability retirement. I have spent four hours filling out forms and reviewing 20 years of medical records to offer supporting medical information about her disability, in addition to seeing the patient weekly. Can I bill for this extra
time, and if so, how should I code it?

Answer: Yes, you can bill for the additional time. The code you need to use depends on where the disability determination request came from. Because this isn't a disability determination for workers' compensation, you can exclude the work-related or medical disability evaluation services codes 99455 and 99456 (... by other than the treating physician ...).

Option 1: If a third party sent you a letter requesting the disability determination, you can report 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 ).

Option 2: If you did not receive a letter of disability determination from a third party, but your patient presented a determination request to you, report 99080 (Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form ).

Dec 3rd, 2013 - agent00711   151 

re: billing 99455

I can send the above in PDF via email if you provide me with your email address.

Dec 3rd, 2013 - blanche22 20 

re: billing 99455

thank you, I printed what you have here and that is a big help.



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