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99455 or Office Visit E/M Code

  1. #1
    Overland Park, KS
    Default 99455 or Office Visit E/M Code
    Medical Coding Books
    I am having a disagreement with a provider on an audit regarding a worker's comp exam. The provider coded the exam using an office/outpatient E/M code from the 99212-99215 range. All we did was an exam on the patient in order to file the report with company. We assumed no care of the patient and did not treat the patient during the encounter. My question is, would we not use 99455/99456 instead since we did not assume care of the patient? If we had treated the patient during the encounter, then the E/M code from the 99212-99215 range would apply correct? I'm very confused here and I appreciate any guideance. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. #2
    I have never used 99455 before myself, but in reading the code description it appears to have the answer to your question in it.

    If I understand correctly, this is not your providers patient.

    99455 Work related or medical disability examination by the treating physician

    This would seem to exclude your provider from using it. Now 99456 is the same code when done by someone other than the treating physician but it doesn't sound like your provider did all the required elements.

    Again, workers comp is not something I have much to do with, but it seems to me this would be billed as an E/M and 99080.

    Just because you didn't take over care doesn't mean you can't use 99212-99215. There has to be some elements of MDM documented and you can level based on history and exam.

    Just my opinion,

    Laura, CPC

  3. #3
    Seacoast- Dover New Hampshire
    I agree with Laura
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  4. #4
    Overland Park, KS
    My thanks to both of you.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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