Reminder: Consultation Codes Not Payable Without Authorization

Reminder: Consultation Codes Not Payable Without Authorization

Here’s an uncontroversial statement: Workers’ comp is constantly changing. In fact, rules and regulations change so quickly that many medical billers and providers struggle to keep up. Case in point? A recent support case our team received about billing using defunct consultation codes.

A lightly-edited version of the message we received earlier this month appears below:

Hello! I am looking for the correct CPT to bill a face-to-face consult with an adjuster provided through an orthopaedic office. Is CPT Code 99245 still valid?

The short answer? No. Effective for all dates of service on or after January 1, 2014, CPT Code 99245 is no longer valid.

The longer answer?  Here’s a passage from the California Code of Regulations § 9789.12.12 (emphasis ours):

“Physicians and qualified non-physician practitioners shall code consultation visits as patient evaluation and management visits utilizing the CPT Evaluation and Management codes that represent where the visit occurs and that identify the complexity of the visit performed.”[1] 

Even if the provider sees the injured worker specifically for a consultation, the provider must bill the consultation using evaluation and management CPT codes. For a patient with a new injury, the consulting physician should bill CPT codes 99201-99205. For an established patient with an established injury, the consulting physician should bill the appropriate CPT code between 99211 and 99215.[2]

This no-reimbursement rule for consultations also applies to consultation reports. But of course, there are exceptions to every rule. From § 9789.12.12 (b) (emphasis ours):

“(b) Consultation reports are bundled into the underlying evaluation and management visit code, and are not separately payable, except as specified in subdivision (c).
(c) The following consultation reports are separately reimbursable:
(1) Consultation reports requested by the Workers’ Compensation Appeals Board or the Administrative Director. Use WC007, modifier -32.
(2) Consultation reports requested by the Qualified Medical Evaluator (“QME”) or Agreed Medical Evaluator (“AME”) in the context of a medical-legal evaluation. Use WC007, modifier -30.”

All of that said, it is still possible for a physician to be reimbursed for consultation codes. Labor Code § 5307.11 allows providers to negotiate reimbursements different from the reimbursements allowed by the Official Medical Fee Schedule (OMFS). These contracts must be negotiated prior to providing services. It is critical that the 5307.11 contract includes the negotiated reimbursement amount, as agreed to by an authorized agent of the claims administrator memorialized in writing.[3]

The moral of the story? It pays to keep up with the ever-changing workers’ comp landscape! Our Work Comp Wizard software, which is the foundational tool of all DaisyBill products, automatically calculates reimbursements using the most recent Medicare files and DWC reimbursement formulas.

Work Comp Wizard subscriptions are just $49 per month, come with a free three-day trial, and are cancellable at any time. You can learn more on our website.


[1] See full text of § 9789.12.12 here.

[2] For a breakdown of “new” versus “established” patients in workers’ comp billing, see our blog.

[3] DaisyBill’s “Contract Pursuant to LC Section 5307.11 Pre-Authorization and Pre-Negotiated Fee Arrangement” can be used to memorialize a pre-authorized reimbursement amount in cases like this.

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