We're not kidding when we say that we heard from A LOT of providers in the last two weeks.  We love talking to you and being a resource for your questions. We thought it might be helpful to make you a list of the top 5 questions we're getting.

Please remember we are not coders--Not one of us is a certified coder, and we don't claim to be. We just have years of experience with workers' comp, and we have spent lots of time with the new regulations and compliance issues.

1) What is changing?  

Well, lots of things.  Reimbursement and CPT codes for starters.  If nothing else educate yourselves on these changes.  Much of the answer varies by specialty but there are some changes that cut across specialties such as reporting.  Continue reading for more on that.

2) I heard we can't bill for a PR-2 anymore (and similarly, I heard a PR-2 is no longer being reimbursed).

Though 99081 is no longer a reimbursable code, PR-2s are now reimbursed with the California specific code WC002.  The reimbursement for it even went up some (think cents, not dollars).

3) Evaluation and Management codes aren't changing, right?  

Wrong.  Consult codes are no longer reimbursable (just like for Medicare).  99242-99245 are no longer payable per the new regs.  Instead you'll need to use the appropriate new patient or established patient E&M code (99201-99205 or 99211-99215).  For more on how to determine if a patient is new or established look here (hint: it is not as clear as it sounds).

4) We read your blog and you said a 99080 is no longer payable (except in special circumstances).  How do we get paid for initial reports or PR-4 reports?  

First off, kudos for reading the blog.  Good news and bad news, except in special circumstances, consultation reports are not reimbursable - the reimbursement is now bundled into the E&M reimbursement.  PR-3 and PR-4 reports are still reimbursable with the new California specific codes WC003 and WC004.

5) What is the deal with record review, 99358?  

The long and short of this answer is 99358 is not a reimbursable code without a prior contract in place under Labor Code 5307.11.  Reimbursement for record review done during an appointment is now bundled into the E&M reimbursement.  Outside of the appointment is a different story.  We think of it like this, we don’t like to work for free and you shouldn’t either.   If you get a request to review past records, prior to reviewing them, ask the adjuster for something in writing authorizing reimbursement.  A client of ours was nice enough to share with us the template they created to request authorization.

Have another question we didn't address? Contact us!

Originally published on Petal to the Metal and migrated to this blog upon the merger of the two blogs.