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E&M Codes: The Bottom Line on 2016 Work Comp Fee Schedule Changes

January 12, 2016 by Catherine Montgomery

In this article, I’ll focus specifically on Evaluation and Management (E&M) codes, which are part of the workers’ comp Physician and Non-Physician Practitioner Fee Schedule.

Spoiler: All E&M fees increase, usually by 5% or more.

In case you missed it, my last article, Important 2016 OMFS Changes, summarizes most of the major changes that the Division of Workers’ Compensation implemented for the Official Medical Fee Schedule (OMFS). Reminder: the OMFS actually includes seven separate fee schedules, one of which is the Physician and Non-Physician Practitioner Fee Schedule.

Physician Evaluation and Management Codes

The table below lists the E&M codes most frequently used by over 1,400 DaisyBillers. Sorted by frequency, the table compares the old December 2015 fees to the new January 2016 fees for E&M codes, in both facility and non-facility settings.

Reimbursement for every E&M code increases by more than 5%, with the exception of procedure code 99215, which increases by 4.77%.

E&M Fee Change Table 1. 2015 Reimbursements vs. 2016 Reimbursements

Procedure Code

Description

Facility

Dec 2015

Fee

Facility

Jan 2016

Fee

Facility

Fee

% Change

Non-Facility

Dec 2015

Fee

Non-Facility

Jan 2016

Fee

Non-Facility

Fee

% Change

99202

Office/outpatient visit new

$60.33

$63.88

5.88%

$92.64

$97.93

5.71%

99203

Office/outpatient visit new

$92.18

$97.13

5.37%

$133.39

$140.55

5.37%

99204

Office/outpatient visit new

$156.34

$164.74

5.37%

$201.77

$212.60

5.37%

99205

Office/outpatient visit new

$203.08

$213.98

5.37%

$252.72

$265.79

5.17%

99211

Office/outpatient visit est

$11.13

$11.73

5.39%

$25.18

$26.53

5.36%

99212

Office/outpatient visit est

$30.71

$32.36

5.37%

$54.59

$57.52

5.37%

99213

Office/outpatient visit est

$61.24

$64.84

5.88%

$89.81

$94.94

5.71%

99214

Office/outpatient visit est

$94.52

$99.60

5.37%

$132.92

$139.56

5.00%

99215

Office/outpatient visit est

$134.10

$140.49

4.77%

$178.59

$187.36

4.91%

The second table below shows the actual monetary impact of these increases. Using the 2015 frequency of use for these E&M codes, DaisyBill projects that in 2016 DaisyBillers will collect over $1,100,000 in additional reimbursements from E&M codes.

That’s an additional one million dollar increase for DaisyBillers’ revenue in 2016. We project that the most popular E&M code, 99214, will generate over $530,000 in additional revenue for DaisyBill providers.

E&M Fee Change Table 2. $1,113,485 additional reimbursement due to DaisyBillers in 2016

Procedure Code

Description

Non-Facility

Dec 2015

Fee

Non-Facility

Jan 2016

Fee

Non-Facility

Fee

% Change

DaisyBiller Additional Reimbursement

99202

Office/outpatient visit new

$92.64

$97.93

5.71%

$4,565.27

99203

Office/outpatient visit new

$133.39

$140.55

5.37%

$29,406.12

99204

Office/outpatient visit new

$201.77

$212.60

5.37%

$68,174.85

99205

Office/outpatient visit new

$252.72

$265.79

5.17%

$147,403.46

99211

Office/outpatient visit est

$25.18

$26.53

5.36%

$4,752.00

99212

Office/outpatient visit est

$54.59

$57.52

5.37%

$3,724.03

99213

Office/outpatient visit est

$89.81

$94.94

5.71%

$110,720.79

99214

Office/outpatient visit est

$132.92

$139.56

5.00%

$539,871.84

99215

Office/outpatient visit est

$178.59

$187.36

4.91%

$204,867.20

TOTAL ADDITIONAL

Reimbursement

$1,113,485.56

For more information, download the slides and video from our recent webinar on the 2016 Physician Fee Schedule changes.

I know these fee schedule changes seem complicated, but DaisyBill is here to help. My next article will provide more information to help you navigate the 2016 Physician Fee Schedule changes. Specifically, the article provides reimbursement comparison tables for radiology and California-specific codes.

For the easiest way to keep up with California fee schedules and rule changes, sign up for the DaisyBill Calculator. Click below for a FREE three day trial and start easy calculations today.

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DaisyBill is a trusted authority on workers’ comp billing. Thousands of work comp professionals attend our webinars and state agencies and professional organizations turn to us for our expertise. We created this blog to help everyone involved in workers’ compensation; sharing news, tips, and data of interest to the community.

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