Billing Code DOS Issue Law Payments Award

Billing Code DOS Issue Law Payments Award DRG 460 64635 64636 93307 93320 1 1-18-to 01-23- February 11, February 11, February 12, February 12, Implants not separately reimbursed for DRG 460 Denial of the two units of 64636 appropriate Denial of the two units of 64636 appropriate For discharges occurring on or after January 01, but before January 01, 2014 an additional allowance shall be made for spinal deceives MS- DRGs 453, 454, 456, 028, 029 and 030 0 For insurance 100 The report submitted identified four facet joint sites; bilateral L3-L4 and bilateral L4-L5. Based on the AMA CPT coding guidelines and documentation submitted no additional The report submitted identified four facet joint sites; bilateral L3-L4 and bilateral L4-L5. Based on the AMA CPT coding guidelines and documentation submitted no additional Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding Initiate Prior payments $2,525.29 seeking additional $703.70 Prior payments $2,525.29 seeking additional $703.70 IBR # payments 101 payments 101 payments 104 payments 104

93325 February 12, 93307 June 21, 93320 June 21, Per Review of the centers for Medicare Medicaid services (CMS) National Correct Coding payments 104 payments 108 payments 108 2

93325 June 21, 99214 99212 February 05, January 31. Down coded from 99214 to 99213 no additional Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination: Initiate Based on a review of the documents the provider did not meet the requirements of CPT 99214: CPT 99214 Office or other outpatient visit for the Evaluation and Management of an established patient which requires at least 2 of these three key components: 1. Detail history 2. Detail examination 3. Medical decision making of moderate complexity 99213 = $52.38 The Provider billed for CPT Evaluation and Management code 99212 and Prolonged Services code 99358. Per the OMFS General Information and Instructions, where the physician is required to spend 15 minutes before and / or after direct (faceto-face) patient contact in reviewing extensive records, tests or in communication with other professionals, the CPT code 99358 may be charged in addition to the basic charge for the appropriate Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not warranted. The payments 108 payments 111 The additional of $66.86 for CPT 99358 is warranted based on the following: PPO Allowance 117 3

99358 January 31. 99086 January 31. Straightforward medical decision making. Prolonged evaluation and management services before and / or after direct patient care. Reproduction of chart notes Evaluation and Management code. The report for date of service 1/31, submitted by the Provider, indicated the provider spent thirty minutes on record review. The total time spent on record review was documented on the last page of the report. 99358 is warranted The Provider billed for CPT Evaluation and Management code 99212 and Prolonged Services code 99358. Per the OMFS General Information and Instructions, where the physician is required to spend 15 minutes before and / or after direct (faceto-face) patient contact in reviewing extensive records, tests or in communication with other professionals, the CPT code 99358 may be charged in addition to the basic charge for the appropriate Evaluation and Management code. The report for date of service 1/31, submitted by the Provider, indicated the provider spent thirty minutes on record review. The total time spent on record review was documented on the last page of the report. 99358 is warranted The second disputed code is CPT 99806 Charts Notes. Based on the OMFS General Information and instructions, request for chart notes shall be in writing and be made only by the Claims requirements of CPT 99358 by the claims administrator was inappropriate Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not warranted. The requirements of CPT 99358 by the claims administrator was inappropriate Based on the documentation submitted an additional allowance CPT 99358 (each 15 minutes) =$33.43 Total time billed 30 minutes = 2 units $33.43 x 2 (units) = $66.86 The additional of $66.86 for CPT 99358 is warranted based on the following: PPO Allowance CPT 99358 (each 15 minutes) =$33.43 Total time billed 30 minutes = 2 units $33.43 x 2 (units) = $66.86 117 payments 117 4

99085 99080 January 31. January 31. Special external photography for documentation of significant medical progress or condition may warrant an additional charge Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form Administrator. A request for chart notes from the claims administrator was not submitted as part of the documentation. Reimbursement for CPT 99086 is not warranted. The third dispute code is charges for photos billed as CPT 99085. Per the OMFS the procedure code 99085 is listed as a By Report service. Procedures without unit values or By Report are defined as unlisted service or one that is rarely provided, unusual or variable may require a report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time effort and equipment necessary to provide the service. The documentation to support the By Report separate was not submitted. Services such as photos are considered procedures that are commonly carried out as an integral part of a total service, and does not warrant separate. The denial of procedure code 99085 by the claims administrator was appropriate. The fourth dispute billed code is CPT 99080. The Provider submitted a report titled Comprehensive Dermatologic Re-evaluation Report and Request for Authorization for follow-up visits and treatment. The provider is the Primary Treating Physician. The contents of the report are consistent with the description and requirements of a Primary Treating Progress Report (PR-2). Per review of the OMFS General Information and Instructions under the of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not warranted. The requirements of CPT 99358 by the claims administrator was inappropriate Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not warranted. The requirements of CPT 99358 by the claims administrator was inappropriate Based on the documentation submitted an additional allowance of the disputed codes CPT 99086, CPT 99085 and CPT 99081 is not warranted. The payments 117 payments 117 5

97799 Modifier 86 97690 Down coded 97691 Down coded February 25, through march 01, February 25, through march 01, February 25, through march 01, Functional restoration program CPT 97799 Unlisted physical medicine service or procedure Modifier 86 is to be used when prior authorization was received for services that exceed the OMFS ground rules Down coded from 9779 86 CPT 97799 Unlisted physical medicine service or procedure Modifier 86 is to be used when prior authorization was received for services that exceed the OMFS ground rules Down coded from 9779 86 CPT 97799 Unlisted physical medicine service or procedure Modifier 86 is to be used when prior authorization was received for services that exceed the OMFS ground rules Reports section CPT 99081 is used when billing for Primary Treating Physician s Progress Reports. The code assignment and pf CPT 99081 by the claims administrator was appropriate Based on a review of the PPO contract, the rate for services rendered would be 90% of the current applicable fee schedule. The Official Medical Fee Schedule does not list a value for CPT 97799. The provider submitted copies of other explanation of reviews demonstrating their usual and customary charge of $6,000.00 for 5 days of functional restoration program services. The should have been on 90% of the billed charges of the providers usual and customary charge of $6,000.00 Based on a review of the PPO contract, the rate for services rendered would be 90% of the current applicable fee schedule. The Official Medical Fee Schedule does not list a value for CPT 97799. The provider submitted copies of other explanation of reviews demonstrating their usual and customary charge of $6,000.00 for 5 days of functional restoration program services. The should have been on 90% of the billed charges of the providers usual and customary charge of $6,000.00 Based on a review of the PPO contract, the rate for services rendered would be 90% of the current applicable fee schedule. The Official Medical Fee Schedule does not list a value for CPT 97799. The provider submitted copies of other explanation of reviews demonstrating their usual and customary charge of $6,000.00 for 5 days of functional restoration program services. The should have been on 90% of the billed charges of the providers usual and customary charge of $6,000.00 requirements of CPT 99358 by the claims administrator was inappropriate of $3,001.45 is warranted for the Official Medical Fee Schedule code 97799. of $3,001.45 is warranted for the Official Medical Fee Schedule code 97799. of $3,001.45 is warranted for the Official Medical Fee Schedule code 97799. amount awarded to the already paid $2,398.55 is $3,001.45 126 amount awarded to the already paid $2,398.55 is $3,001.45 126 amount awarded to the already paid $2,398.55 is $3,001.45 126 6

99244 99213 99080 February 08, February 08, February 08, Office consultation for a new or established patient, which requires these 3 key components. A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity Office or other outpatient visit for the evaluation and management of an established patient which requires at least 2 of these 3 key components.: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Special reports such as insurance forms, more than the information conveyed in the usual medical communications Per the OMFS Information and Instructions, the referral for the transfer of the total care or specific care of a patient from one physician to another does not constitute a consultation. The of 99244 is not warranted. Based on the review of the medical record criteria of CPT 99213 was met. Expanded problem focused history is defined as meeting the requirements of or documenting the chief complaint, a brief history of present illness and problem pertinent system review. The patient s chief complaint was documented, duration of complaint associated signs and symptoms of illness were discussed as well as a review of the body system directly related to the chief complaint. The provider prescribed medications and reviewed the Primary Physician s Initial report. The medical decision appears to be low complexity. The provider submitted a report titled Report of Psychiatric Consultation. The report submitted was addressed to the Primary Treating Physician. The Provider prescribed medication and requested a follow-up visit, therefore, is considered a Secondary The documentation submitted warranted of the Evaluation and Management services. The denial of the report code 99080 by the Claims Administrator was appropriate/ The criteria of 99213 was met based on the review of the medical record for date of service 2/8/ The documentation submitted warranted of the Evaluation and Management services. The denial of the report code 99080 by the Claims Administrator was appropriate/ The criteria of 99213 was met based on the review of the medical record for date of service 2/8/ Per the OMFS information and Instruction Guidelines, reports submitted by the 0 Ordered $56.93 / 99213 130 Ordered $56.93 130 130 7

or standard reporting form Treating Physician to the worker. Per the OMFS information and Instruction Guidelines, reports submitted by the Secondary Physician to the Primary Treating Physician are not Reimbursable Secondary Physician to the Primary Treating Physician are not Reimbursable Based on a review of the final explanation of review, it appears the Claims Administrator reimbursed the Provider for four units of CPT code 99358. The provider billed the code 99358 (13 units) and report charge 99080. The provider documented at the beginning the report, three hours and 15 minutes of time spent on record review, the Provider s own file and report preparation. The provider documented and billed for thirteen units of CPT 99358. The partial payment of CPT 99358 was inappropriate Prolonged evaluation and management service 99358 January 06, before and / or after direct (face-to-face) patient care (e.g. review of extensive records, job analysis, evaluation of ergonomic status work limitation, work capacity or communication with other professional and / or the patient / family); each 15 minutes CPT code 99358 may be charged in addition to basic charge for the appropriate Evaluation and Management Code. OMFS Evaluation and Management code description indicates the code 99358 is used when the physician provides prolonged services not involving direct (face-toface) care that is beyond the usual services in either the inpatient or outpatient setting. The code 99358 is to be reported in addition to other physician service, including evaluation and management services at any level and report charge (99080) FS Allowance $425.18 Provider billed 195 minutes = 13 units $425.18- $130.82 (previously paid) = 294.36 166 99080 January 06, Special reports such as CPT code 99358 may be charged in addition to Based on a review 166 8

99080 insurance forms, more than the information conveyed in the usual medical communications or standard reporting form. January 25, CPT 99080 Special reports such insurance forms, more than the information conveyed in the usual medical communications or standard reporting form basic charge for the appropriate Evaluation and Management Code. OMFS Evaluation and Management code description indicates the code 99358 is used when the physician provides prolonged services not involving direct (face-toface) care that is beyond the usual services in either the inpatient or outpatient setting. The code 99358 is to be reported in addition to other physician service, including evaluation and management services at any level and report charge (99080) The provider submitted a Primary Treating Physician Supplemental Report Review of Medical Records report. The report documented a review of an e-ray and provider comments. The type of report submitted by the provider was not a Primary Treating Physician Progress Report (PR-2), or separately reimbursable report as described in the of the final explanation of review, it appears the Claims Administrator reimbursed the Provider for four units of CPT code 99358. The provider billed the code 99358 (13 units) and report charge 99080. The provider documented at the beginning the report, three hours and 15 minutes of time spent on record review, the Provider s own file and report preparation. The provider documented and billed for thirteen units of CPT 99358. The partial payment of CPT 99358 was inappropriate There is no additional warranted per the Official Medical Fee Schedule code 99080 0 0 9

OMFS General Information and Instructions Separately Reimbursable Treatment Reports section, therefore the denial of the report code 99080 was correct 10