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:
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 No. Effective for all dates of service on or after January 1, 2014, CPT Code 99245 is no longer valid.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):
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):
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.
[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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