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 [...]