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99455 - I have a orthopedic surgeon

  1. Default 99455 - I have a orthopedic surgeon
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    I have a orthopedic surgeon that has a very significant workers comp practice (carpel tunnel) etc. He bills workers comp payors using code 99455. He advises that the code states that it is for work related injuries and disability matters. He says he does all the things the code requires H&P, diagnosis some workers comp form completion etc (I don't have the code book for the details). He is going to send me one of his charts to show his documentation of what he does. He knows some other specialists who also bill that code for workers comp cases but a lot do not. He said he understands that it is most frequently used for disability matters. He just wants to make sure the code is appropriate for him to use.
    As long as he follows the guidelines in the manual, is this the correct code to use?
    Kathi

  2. #2
    Default
    Sorry, but I do not know anything about code 99455, but found some info in the CPT Assist. Everything below is copied and pasted. I have not changed any words or omitted anything.Special Evaluation and Management Services Added to CPT 1995 However, I do think and someone can correct me if I am wrong, but if you are providing "treatment" then you would use the appropiate E/M code.



    A new series of codes, Basic Life and/or Disability Evaluation Services and Work Related or Medical Disability Evaluation Services, was added to CPT in 1995. These codes were added to report specific services that occur when completing evaluations for life insurance and/or disability claims, as well as work related or other medical disability examinations.

    The life insurance industry estimates that about $5 billion is paid each year for medical examinations and evaluations performed on applicants for life insurance. In addition, the role of the independent medical examiner is important when accidental medical trauma, covered by casualty carriers, has occurred. It is a specific type of examination and evaluation that is financed as the cost of doing business (the "expense" side of a life/disability insurer), rather than from the funds for the treatment of the injured policy holder (the "loss" side).

    These services are separate and distinct from other evaluation and management services. These codes are to be used to report evaluations performed in order to establish baseline information, prior to life or disability insurance certificates being issued. The service is performed in an office or other setting, and applies to both new and established patients. When using these codes, NO active management of the problem(s) is undertaken during the encounter.

    If other evaluation and management services and/or procedures are performed on the same date, the appropriate evaluation and management or procedure code(s) can be reported in addition to these codes. In this case Modifier -25 should be appended to the evaluation and management service, if performed on the same date.

    Basic Life and/or Disability Evaluation Services

    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.

    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 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.

    99456 Work related or medical disability examination by other than 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.

    For Example:

    A patient makes an appointment to see his family physician for a physical examination, required to qualify for a new life insurance policy. The physician completes a medical history, as required by the Life Insurance Company, which consists of an abbreviated examination of height, weight, and blood pressure, as well as collection of specimen samples required for laboratory tests. The physician also completes several forms, provided by the life insurance company, to certify that the information is complete. If this is the only service provided, then the physician should use CPT code 99450 for this evaluation and management service. The ICD-9 diagnosis code would be V70.3, "other medical examination for administrative purposes." This is located in the index under "Examination," subterm "Medical," subterm "Insurance certification."

    If a physician, through the course of a basic-life examination on an established patient, finds a patient to be severely overweight with high blood pressure and counsels the patient for 25 minutes during the visit, on weight control, diet, and exercise, the physician may then report an additional code for the counseling. In this case, 99214-25 will be coded in addition to 99450. CPT code 99214 is chosen because counseling dominates (more than 50%) the evaluation and management portion of the visit (excludes services provided that are described in this section), therefore time is considered the key or controlling factor to qualify for a particular level of E/M services. The preventive medicine individual counseling code is NOT appropriate because the patient had pre-existing symptoms (overweight, high blood pressure). Refer to the guidelines on page 37 in CPT 1995 and the CPT Assistant article in Winter 1994 for further clarification on reporting preventive medicine individual counseling.


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    99080 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form

    Many times physicians are asked to fill out brief standard reports (eg, return to work forms, hospital discharge summaries). Completion of these routine forms are not reported separately, including the forms described in the nursing facility assessment codes.

    There are occasions when a physician must fill other than a standard reporting for (eg, detailed forms related to accidents, injuries, Worker's Compensation); code 99080 may be used to report the completion of these special reports. (See also new codes 99450, 99455, 99456 that describe special evaluation and management services related to disability evaluation.)

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