Newly Payable Workers Compensation Codes for Non-Face-to-Face Service. CPT / l 1

Transcription

1 CPT & Newly Payable Workers Compensation Codes for Non-Face-to-Face Service DaisyBill 2017 CPT / l 1

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24 Register at DaisyBill.com DaisyBill 2017 CPT / l 24

25 CPT / Prolonged Service Without Direct Patient Contact DaisyBill 2017 CPT / l 25

26 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 26

27 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 27

28 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 28

29 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 29

30 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 30

31 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 31

32 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 32

33 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 33

34 Physician Fee Schedule Historical Reimbursement Current Start Date 7/1/2004 1/1/2014 3/1/2015 1/1/2016 3/1/2017 End Date 12/31/2013 2/28/ /31/2015 2/28/2017 Regulation (a) (b) (c) (d) Fee Schedule Table A RBRVU RBRVU RBRVU RBRVU Effective Day Count 3, DaisyBill 2017 CPT / l 34

35 Regulation /1/ /31/2013 Start Date 7/1/2004 1/1/2014 3/1/2015 1/1/2016 3/1/2017 End Date 12/31/2013 2/28/ /31/2015 2/28/2017 Regulation (a) (b) (c) (d) Fee Schedule Table A RBRVU RBRVU RBRVU RBRVU Effective Day Count 3, DaisyBill 2017 CPT / l 35

36 Regulation Table A 7/1/ /31/2013 Start Date 7/1/2004 1/1/2014 3/1/2015 1/1/2016 3/1/2017 End Date 12/31/2013 2/28/ /31/2015 2/28/2017 Regulation (a) (b) (c) (d) Fee Schedule Table A RBRVU RBRVU RBRVU RBRVU Effective Day Count 3, Table A DaisyBill 2017 CPT / l 36

37 Table A: $36.34 Reimbursement DaisyBill 2017 CPT / l 37

38 Table A: Not Listed DaisyBill 2017 CPT / l 38

39 Instructions: 15 Minutes Record Review DaisyBill 2017 CPT / l 39

40 99358 DWC General Instructions Where the physician is required to spend 15 or more minutes before and/or after direct (face-to-face) patient contact in reviewing extensive records, tests or in communication with other professionals, the CPT code may be charged in addition to the basic charge for the appropriate Evaluation and Management coce. CPT code may also be used where the physician is required to spend 15 or more minutes reviewing records or tests, a job analysis, an evaluation of ergonomic status, work limitations, or work capacity when there is no direct (face-to-face) contact DaisyBill 2017 CPT / l 40

41 Regulation Table A 7/1/ /31/2013 Start Date 7/1/2004 1/1/2014 3/1/2015 1/1/2016 3/1/2017 End Date 12/31/2013 2/28/ /31/2015 2/28/2017 Regulation (a) (b) (c) (d) Fee Schedule Table A RBRVU RBRVU RBRVU RBRVU Effective Day Count 3, Table A DaisyBill 2017 CPT / l 41

42 Reform DaisyBill 2017 CPT / l 42

43 SB 863 RBRVU-Based Physician Fee Schedule Services Rendered as of January 1, 2014 Table A DaisyBill 2017 CPT / l 43

44 48 Physician Fee Schedule Regulations DaisyBill 2017 CPT / l 44

45 48 Physician Fee Schedule Regulations 7 Base Maximum Fee Regulations [(Work RVU * Statewide Work GAF) + (Non-Facility PE RVU * Statewide PE GAF) + (MP RVU * Statewide MP GAF)] * Conversion Factor (CF) = Base Maximum Fee DaisyBill 2017 CPT / l 45

46 48 Physician Fee Schedule Regulations 7 Base Maximum Fee Regulations + 40 Fee-Affecting Regulations DaisyBill 2017 CPT / l 46

47 Adopted and Adapted Medicare Rules Status Codes Professional Component (PC)/Technical Component (TC) Indicator Coding; Current Procedural Terminology, Fourth Edition Evaluation and Management: Coding - New Patient; Documentation Consultation Services Coding - Use of Visit Codes Correct Coding Initiative. DaisyBill 2017 CPT / l 47

48 DWC Status Code Meanings Status Codes The Medicare Status Codes have been adapted for workers compensation and have the following meanings: A = Active Code. These codes are paid separately under the physician fee schedule. There will be RVUs for codes with this status. B = Bundled Code. Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient). C = If payable, these codes will be paid By Report, generally following review of documentation such as an operative report. E = If payable: (a) HCPCS codes beginning with J or P, maximum fee is determined according section (b) Other codes are paid under the applicable fee schedule contained in Section , or if none of those schedules is applicable the code is payable By Report. I = Except as otherwise provided, not valid code for workers' compensation physician billing. See section J = Anesthesia Services. The intent of this value is to facilitate the identification of anesthesia services. There are no RVUs and no payment amounts for these codes in the National Physician Fee Schedule Relative Value File. Instead, the Anesthesia Base Units file is to be used to determine the base units for these codes. M = Measurement codes. Used for reporting purposes only. N = If payable, these CPT codes are paid using the listed RVUs; but if no RVUs are listed, then By Report. See section P = Bundled/Excluded Codes. There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule. -If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to physician service.) -If the item or service is covered as other than incident to a physician Service, it is excluded from the fee schedule (i.e., colostomy supplies) and should be paid under the other portions of the fee schedule. R = If payable, these codes will be paid pursuant to section T = Injections. There are RVUS and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made. X = No RVUS or payment amounts are shown for these codes. If payable, these codes are paid under the applicable fee schedule contained in Sections , or if none of those schedules is applicable the code is payable By Report. (Examples DaisyBill of 2017 services payable under another fee schedule are ambulance services and clinical diagnostic laboratory CPT services.) / l 48

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50 99358 & 99359: Status Code B - Bundled SB 863 RBRVU-Based Physician Fee Schedule Dates of Service: 1/1/2104-2/28/2017 Start Date 7/1/2004 1/1/2014 3/1/2015 1/1/2016 3/1/2017 End Date 12/31/2013 2/28/ /31/2015 2/28/2017 Regulation (a) (b) (c) (d) Fee Schedule Table A RBRVU RBRVU RBRVU RBRVU Effective Day Count 3, DaisyBill 2017 CPT / l 50

51 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 51

52 2017 Workers Compensation OMFS Updates A FREE WEBINAR ON CALIFORNIA WORKERS COMPENSATION DaisyBill 2017 CPT / l 52

53 DaisyBill 2017 CPT / l 53

54 2017 Physician Fee Schedule Changes Effective Dates of Service: March 1, 2017 DaisyBill 2017 CPT / l 54

55 Update Table (d) Services Rendered On or After 3/1/2017. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director. Medicare RVU17A CMS Medicare National Physician Fee Schedule Relative Value File [Zip] For services rendered on or after March 1, 2017: RVU17A (January 2017 release) [ZIP, 3MB] RVU17A (Excluding Attachment A) PPRRVU17_V1219 OPPSCAP_V1219 Excluding: 17LOCCO ANES_V0101 CY2017_GPCIs DaisyBill 2017 CPT / l 55

56 Update Table (d) Services Rendered On or After 4/1/2017. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director. April 1: Medicare RVU17B CMS Medicare National Physician Fee Schedule Relative Value File [Zip] For services rendered on or after March 1, 2017: RVU17A (January 2017 release) [ZIP, 3MB] RVU17A (Excluding Attachment A) PPRRVU17_V1219 OPPSCAP_V1219 Excluding: 17LOCCO ANES_V0101 CY2017_GPCIs For services rendered on or after April 1, 2017: RVU17B [ZIP, 3MB] RVU17B (Excluding Attachment A) PPRRVU17_V0209 OPPSCAP_V0215 Excluding: 17LOCCO ANES_V0101 CY2017_GPCIs DaisyBill 2017 CPT / l 56

57 Update Table (d) Services Rendered On or After 3/1/2017. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director. Download RVU17A CMS Medicare National Physician Fee Schedule Relative Value File [Zip] For services rendered on or after March 1, 2017: RVU17A (January 2017 release) [ZIP, 3MB] RVU17A (Excluding Attachment A) PPRRVU17_V1219 OPPSCAP_V1219 Excluding: 17LOCCO ANES_V0101 CY2017_GPCIs DaisyBill 2017 CPT / l 57

58 Update Table (d) Services Rendered On or After 4/1/2017. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director. April 1: Medicare RVU17B CMS Medicare National Physician Fee Schedule Relative Value File [Zip] For services rendered on or after March 1, 2017: RVU17A (January 2017 release) [ZIP, 3MB] RVU17A (Excluding Attachment A) PPRRVU17_V1219 OPPSCAP_V1219 Excluding: 17LOCCO ANES_V0101 CY2017_GPCIs For services rendered on or after April 1, 2017: RVU17B [ZIP, 3MB] RVU17B (Excluding Attachment A) PPRRVU17_V0209 OPPSCAP_V0215 Excluding: 17LOCCO ANES_V0101 CY2017_GPCIs DaisyBill 2017 CPT / l 58

59 HCPCS MOD DESCRIPTION Prolong service w/o contact Prolong serv w/o contact add STATUS CODE A A WORK RVU NON-FAC PE RVU NON-FAC NA INDICATOR FACILITY PE RVU FACILITY NA INDICATOR MP RVU NON-FACILITY TOTAL FACILITY TOTAL PCTC IND 0 0 GLOB DAYS XXX ZZZ PRE OP 0 0 INTRA OP 0 0 POST OP 0 0 MULT PROC 0 0 BILAT SURG 0 0 ASST SURG 0 0 CO- SURG 0 0 TEAM SURG 0 0 ENDO BASE CONV FACTOR PHYSICIAN SUPERVISION OF DIAGNOSTIC PROCEDURES 9 9 CALCULATION FLAG 0 0 DIAGNOSTIC DaisyBill IMAGING 2017 FAMILY INDICATOR 99 CPT / l 59

60 HCPCS MOD DESCRIPTION Prolong service w/o contact Prolong serv w/o contact add STATUS CODE A A WORK RVU NON-FAC PE RVU NON-FAC NA INDICATOR FACILITY PE RVU FACILITY NA INDICATOR MP RVU NON-FACILITY TOTAL FACILITY TOTAL PCTC IND 0 0 GLOB DAYS XXX ZZZ PRE OP 0 0 INTRA OP 0 0 POST OP 0 0 MULT PROC 0 0 BILAT SURG 0 0 ASST SURG 0 0 CO- SURG 0 0 TEAM SURG 0 0 ENDO BASE CONV FACTOR PHYSICIAN SUPERVISION OF DIAGNOSTIC PROCEDURES 9 9 CALCULATION FLAG 0 0 DIAGNOSTIC DaisyBill IMAGING 2017 FAMILY INDICATOR 99 CPT / l 60

61 Status Codes Changed: 3/1/2017 CMS Medicare National Physician Fee Schedule Relative Value File [Zip] CY2017_GPCIs HCPCS MOD DESCRIPTION Prolong service w/o contact Prolong serv w/o contact add STATUS CODE A A WORK RVU NON-FAC PE RVU NON-FAC NA INDICATOR FACILITY PE RVU FACILITY NA INDICATOR For services rendered on or after March 1, 2017: RVU17A (January 2017 release) [ZIP, 3MB] RVU17A (Excluding Attachment A) PPRRVU17_V1219 OPPSCAP_V1219 Excluding: 17LOCCO ANES_V0101 MP RVU NON-FACILITY TOTAL FACILITY TOTAL PCTC IND 0 0 GLOB DAYS XXX ZZZ DaisyBill 2017 PRE OP 0 0 CPT / l 61

62 DWC Status Code Meanings Status Codes The Medicare Status Codes have been adapted for workers compensation and have the following meanings: A = Active Code. These codes are paid separately under the physician fee schedule. There will be RVUs for codes with this status. B = Bundled Code. Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient). C = If payable, these codes will be paid By Report, generally following review of documentation such as an operative report. E = If payable: (a) HCPCS codes beginning with J or P, maximum fee is determined according section (b) Other codes are paid under the applicable fee schedule contained in Section , or if none of those schedules is applicable the code is payable By Report. I = Except as otherwise provided, not valid code for workers' compensation physician billing. See section J = Anesthesia Services. The intent of this value is to facilitate the identification of anesthesia services. There are no RVUs and no payment amounts for these codes in the National Physician Fee Schedule Relative Value File. Instead, the Anesthesia Base Units file is to be used to determine the base units for these codes. M = Measurement codes. Used for reporting purposes only. N = If payable, these CPT codes are paid using the listed RVUs; but if no RVUs are listed, then By Report. See section P = Bundled/Excluded Codes. There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule. -If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to physician service.) -If the item or service is covered as other than incident to a physician Service, it is excluded from the fee schedule (i.e., colostomy supplies) and should be paid under the other portions of the fee schedule. R = If payable, these codes will be paid pursuant to section T = Injections. There are RVUS and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made. X = No RVUS or payment amounts are shown for these codes. If payable, these codes are paid under the applicable fee schedule contained in Sections , or if none of those schedules is applicable the code is payable By Report. (Examples DaisyBill of 2017 services payable under another fee schedule are ambulance services and clinical diagnostic laboratory CPT services.) / l 62

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65 HCPCS MOD DESCRIPTION Prolong service w/o contact Prolong serv w/o contact add STATUS CODE A A WORK RVU NON-FAC PE RVU NON-FAC NA INDICATOR FACILITY PE RVU FACILITY NA INDICATOR MP RVU NON-FACILITY TOTAL FACILITY TOTAL PCTC IND 0 0 GLOB DAYS XXX ZZZ PRE OP 0 0 INTRA OP 0 0 POST OP 0 0 MULT PROC 0 0 BILAT SURG 0 0 ASST SURG 0 0 CO- SURG 0 0 TEAM SURG 0 0 ENDO BASE CONV FACTOR PHYSICIAN SUPERVISION OF DIAGNOSTIC PROCEDURES 9 9 CALCULATION FLAG 0 0 DIAGNOSTIC DaisyBill IMAGING 2017 FAMILY INDICATOR 99 CPT / l 65

66 Base Maximum Fee Formulas Calculation of the Maximum Reasonable Fee - Services Other than Anesthesia (a) Non-facility site of service fee calculation: [(Work RVU * Statewide Work GAF) + (Non-Facility PE RVU * Statewide PE GAF) + (MP RVU * Statewide MP GAF)] * Conversion Factor (CF) = Base Maximum Fee Key: RVU = Relative Value Unit GAF = Average Statewide Geographic Adjustment Factor Work = Physician Work PE = Practice Expense MP = Malpractice Expense (b) Facility site of service fee calculation: [(Work RVU * Statewide Work GAF) + (Facility PE RVU * Statewide PE GAF) + (MP RVU * Statewide MP GAF)] * Conversion Factor (CF) = Base Maximum Fee Key: RVU = Relative Value Unit GAF = Average Statewide Geographic Adjustment Factor Work = Physician Work PE = Practice Expense MP = Malpractice Expense DaisyBill 2017 CPT / l 66

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69 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 69

70 DWC Adopted and Adapted Rules Status Codes Professional Component (PC)/Technical Component (TC) Indicator Coding; Current Procedural Terminology, Fourth Edition Evaluation and Management: Coding - New Patient; Documentation Consultation Services Coding - Use of Visit Codes Correct Coding Initiative. DaisyBill 2017 CPT / l 70

71 Coding; Current Procedural Terminology (a) The coding, modifiers, guidelines, appendices and all other provisions of Current Procedural Terminology, Fourth Edition ( CPT ), published by the American Medical Association are applicable to the bills submitted for physician and non-physician practitioner services, except: (1) any provision in the Physician Fee Schedule that conflicts with a provision in CPT will take precedence over the CPT, and (2) as otherwise specified in regulation. See section for the version of the CPT by date of service. DaisyBill 2017 CPT / l 71

72 48 Physician Fee Schedule Regulations 7 Base Maximum Fee Regulations + 40 Fee-Affecting Regulations + 1 Update Table Regulation (d) Update Table: Effective 3/1/2017 DaisyBill 2017 CPT / l 72

73 Coding; Current Procedural Terminology (a) The coding, modifiers, guidelines, appendices and all other provisions of Current Procedural Terminology, Fourth Edition ( CPT ), published by the American Medical Association are applicable to the bills submitted for physician and non-physician practitioner services, except: (1) any provision in the Physician Fee Schedule that conflicts with a provision in CPT will take precedence over the CPT, and (2) as otherwise specified in regulation. See section for the version of the CPT by date of service Update Table Current Procedural Terminology (CPT ) CPT org/store/ DaisyBill 2017 CPT / l 73

74 99358 / Guidelines DaisyBill 2017 CPT / l 74

75 CPT Prolonged evaluation and management service before and/or after direct patient care; first hour each additional 30 minutes (List separately in addition to code for prolonged service) (Use in conjunction with 99358) (Do not report 99358, during the same month with ) (Do not report 99358, when performed during the service time of codes or 99496) DaisyBill 2017 CPT / l 75

76 CPT Prolonged evaluation and management service before and/or after direct patient care; first hour each additional 30 minutes (List separately in addition to code for prolonged service) (Use in conjunction with 99358) (Do not report 99358, during the same month with ) (Do not report 99358, when performed during the service time of codes or 99496) DaisyBill 2017 CPT / l 76

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78 99358 / CPT Guidelines DaisyBill 2017 CPT / l 78

79 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 79

80 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 80

81 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 81

82 99358 / CPT Guidelines DaisyBill 2017 CPT / l 82

83 Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same session of an evaluation and management service, nor ii. additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and b. is beyond the usual physician or other qualified health care professional service time. 2. Prolonged service is to be reported in relation to other physician or other qualified health care professional services, a. including evaluation and management services at any level. 3. Prolonged service may be reported on a different date than the primary service to which it is related. a. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care i. has occurred or ii. will occur, and b. ongoing patient management. 5. A typical time for the primary service need not be established within the CPT code set. DaisyBill 2017 CPT / l 83

84 Neither Face-to-Face Time During E/M Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same session of an evaluation and management service, nor DaisyBill 2017 CPT / l 84

85 NOR Additional Unit/Floor Time Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same ii. session of an evaluation and management service, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and DaisyBill 2017 CPT / l 85

86 Beyond the Usual Service Time Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same ii. session of an evaluation and management service, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and b. is beyond the usual physician or other qualified health care professional service time. DaisyBill 2017 CPT / l 86

87 Beyond Usual Service Time & Do Not Report Face-to-Face Time Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same ii. session of an evaluation and management service, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and b. is beyond the usual physician or other qualified health care professional service time. DaisyBill 2017 CPT / l 87

88 Includes Review of OTHER Service Records Prolonged Service Instructions 2. Prolonged service is to be reported in relation to other physician or other qualified health care professional services, a. including evaluation and management services at any level. DaisyBill 2017 CPT / l 88

89 Different Date Allowed Prolonged Service Instructions 3. Prolonged service may be reported on a different date than the primary service to which it is related. a. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. DaisyBill 2017 CPT / l 89

90 Must Relate to Face-to-Face Care Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care. i. has occurred or ii. will occur, and DaisyBill 2017 CPT / l 90

91 Must Relate to Ongoing Patient Management Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care i. has occurred or ii. will occur, and b. ongoing patient management. DaisyBill 2017 CPT / l 91

92 Primary Service: Typical Time Not Required Prolonged Service Instructions 5. A typical time for the primary service need not be established within the CPT code set. DaisyBill 2017 CPT / l 92

93 Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same session of an evaluation and management service, nor ii. additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and b. is beyond the usual physician or other qualified health care professional service time. 2. Prolonged service is to be reported in relation to other physician or other qualified health care professional services, a. including evaluation and management services at any level. 3. Prolonged service may be reported on a different date than the primary service to which it is related. a. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care i. has occurred or ii. will occur, and b. ongoing patient management. 5. A typical time for the primary service need not be established within the CPT code set. DaisyBill 2017 CPT / l 93

94 99358 / CPT Guidelines DaisyBill 2017 CPT / l 94

95 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 95

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97 Time Requirements 1. Codes and are used to report a. the total duration of non-face-to-face time spent by a physician or other qualified health care professional i. on a given date providing prolonged service, ii. even if the time spent by the physician or other qualified health care professional on that date is not continuous. 2. Code is used to report a. the first hour of prolonged service i. on a given date ii. regardless of the place of service. b. It should be used only once per date. c. Prolonged service of less than 30 minutes total duration on a given date is not separately reported. 3. Code is used to report a. each additional 30 minutes i. beyond the first hour ii. regardless of the place of service. b. It may also be used to report the final 15 to 30 minutes prolonged service on a given date. c. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. DaisyBill 2017 CPT / l 97

98 Report Total Non-Face-to-Face Time per Day Time Requirements 1. Codes and are used to report a. the total duration of non-face-to-face time spent by a physician or other qualified health care professional i. on a given date providing prolonged service, DaisyBill 2017 CPT / l 98

99 Report Total Non-Face-to-Face Time per Day Even If Not Continuous Time Requirements 1. Codes and are used to report a. the total duration of non-face-to-face time spent by a physician or other qualified health care professional i. on a given date providing prolonged service, ii. even if the time spent by the physician or other qualified health care professional on that date is not continuous. = + DaisyBill 2017 CPT / l 99

100 99358 Used to Report First Hour Prolonged Service Spent per Day Time Requirements 2. Code is used to report a. the first hour of prolonged service i. on a given date DaisyBill 2017 CPT / l 100

101 99358 Used to Report First Hour Prolonged Service Spent per Day Time Requirements 2. Code is used to report a. the first hour of prolonged service i. on a given date ii. regardless of the place of service. DaisyBill 2017 CPT / l 101

102 99358 Used Only Once per Day Time Requirements 2. Code is used to report a. the first hour of prolonged service i. on a given date ii. regardless of the place of service. b. It should be used only once per date. 1 DaisyBill 2017 CPT / l 102

103 99358 Used to Report 30+ Minutes Prolonged Service Time Requirements 2. Code is used to report a. the first hour of prolonged service i. on a given date ii. regardless of the place of service. b. It should be used only once per date. c. Prolonged service of less than 30 minutes total duration on a given date is not separately reported. DaisyBill 2017 CPT / l 103

104 99358 Not Used to Report Less Than 30 Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ DaisyBill 2017 CPT / l 104

105 99358 Used to Report Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ DaisyBill 2017 CPT / l 105

106 99359 Used to Report Each Additional 30 Minutes Beyond First Hour Time Requirements 3. Code is used to report a. each additional 30 minutes i. beyond the first hour DaisyBill 2017 CPT / l 106

107 99359 Used to Report Each Additional 30 Minutes Beyond the First Hour Time Requirements 3. Code is used to report a. each additional 30 minutes i. beyond the first hour ii. regardless of the place of service. DaisyBill 2017 CPT / l 107

108 99359 Used to Report Final Minutes of Prolonged Service Time Requirements 3. Code is used to report a. each additional 30 minutes i. beyond the first hour ii. regardless of the place of service. b. It may also be used to report the final 15 to 30 minutes of prolonged service on a given date. DaisyBill 2017 CPT / l 108

109 99359 Not Used to Report Less Than 15 Minutes of Prolonged Service Time Requirements 3. Code is used to report a. each additional 30 minutes i. beyond the first hour ii. regardless of the place of service. b. It may also be used to report the final 15 to 30 minutes prolonged service on a given date. c. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. DaisyBill 2017 CPT / l 109

110 99359 Not Used to Report Less Than 15 Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ DaisyBill 2017 CPT / l 110

111 99359 Used to Report 15+ Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ DaisyBill 2017 CPT / l 111

112 99359 Not Used to Report Less Than 15 Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ :30 1:44 $ $71.96 $ DaisyBill 2017 CPT / l 112

113 99359 Used to Report 15+ Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ :30 1:44 $ $71.96 $ :45 1:59 $ $ $ DaisyBill 2017 CPT / l 113

114 99358 / Time Card Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ :30 1:44 $ $71.96 $ :45 1:59 $ $ $ :00 2:14 $ $ $ :15 2:29 $ $ $ :30 2:44 $ $ $ :45 2:59 $ $ $ :00 3:14 $ $ $ :15 3:29 $ $ $ :30 3:44 $ $ $ :45 3:59 $ $ $ :00 4:14 $ $ $ :15 4:29 $ $ $ DaisyBill 2017 CPT / l 114

115 Download / Time Card Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ :30 1:44 $ $71.96 $ :45 1:59 $ $ $ :00 2:14 $ $ $ :15 2:29 $ $ $ :30 2:44 $ $ $ :45 2:59 $ $ $ :00 3:14 $ $ $ :15 3:29 $ $ $ :30 3:44 $ $ $ :45 3:59 $ $ $ :00 4:14 $ $ $ :15 4:29 $ $ $ DaisyBill 2017 CPT / l 115

116 DaisyBill 2017 CPT / l 116

117 DaisyBill 2017 CPT / l 117

118 Time Requirements 1. Codes and are used to report a. the total duration of non-face-to-face time spent by a physician or other qualified health care professional i. on a given date providing prolonged service, ii. even if the time spent by the physician or other qualified health care professional on that date is not continuous. 2. Code is used to report a. the first hour of prolonged service i. on a given date ii. regardless of the place of service. b. It should be used only once per date. c. Prolonged service of less than 30 minutes total duration on a given date is not separately reported. 3. Code is used to report a. each additional 30 minutes i. beyond the first hour ii. regardless of the place of service. b. It may also be used to report the final 15 to 30 minutes prolonged service on a given date. c. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. DaisyBill 2017 CPT / l 118

119 99358 / CPT Guidelines DaisyBill 2017 CPT / l 119

120 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 120

121 DaisyBill 2017 CPT / l 121

122 Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). 2. Do not report 99358, during the same month with Do not report 99358, when performed during the service time of codes or DaisyBill 2017 CPT / l 122

123 Do Not Report / Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). DaisyBill 2017 CPT / l 123

124 Do Not Report / Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). DaisyBill 2017 CPT / l 124

125 Do Not Report / Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). DaisyBill 2017 CPT / l 125

126 Do Not Report / Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). DaisyBill 2017 CPT / l 126

127 Do Not Report / Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). DaisyBill 2017 CPT / l 127

128 Not in Same Month With Chronic Care Management Incompatible Codes 2. Do not report 99358, during the same month with DaisyBill 2017 CPT / l 128

129 Not When Performed During Transitional Care Management Incompatible Codes 3. Do not report 99358, when performed during the service time of codes or DaisyBill 2017 CPT / l 129

130 Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). 2. Do not report 99358, during the same month with Do not report 99358, when performed during the service time of codes or DaisyBill 2017 CPT / l 130

131 99358 / Guidelines DaisyBill 2017 CPT / l 131

132 99358 / CPT Guidelines DaisyBill 2017 CPT / l 132

133 DaisyBill 2017 CPT / l 133

134 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 134

135 Workers Comp Billing Regulations & Rules DaisyBill 2017 CPT / l 135

136 Reporting Requirements DaisyBill 2017 CPT / l 136

137 Reporting Requirements Service A physician provides an Evaluation and Management consultation. The provider uses any of the following modifiers: 22, 23, or 25. The provider uses a code that is designated payable By Report, per the OMFS. The OMFS indicates that a report is required. The provider furnished either professional or facility Surgery Services. The OMFS requires an invoice or proof of cost for reimbursement. A claims administrator or claims administrator agent requested additional information in support of a billed code prior to bill submission. The provider submits a paper bill Required Report Narrative Report Descriptive Report Descriptive Report of the procedure, including treatment type, procedure length, equipment used, and level of skill necessary to perform the treatment. Descriptive Report Operative Report Invoice or Proof of Documented Paid Costs Varies by Request Any written authorization for services received by the physician. DaisyBill 2017 CPT / l 137

138 No / Reporting Requirements DaisyBill 2017 CPT / l 138

139 200+ Payment Examples procedure code units bill date of service date posted claims admin name payment amount cents expected payment cents percentage /6/2017 3/15/2017 Sedgwick Claims Management Services % /3/2017 3/21/2017 Sentry Insurance % /3/2017 3/21/2017 Insurance Company of the West % /3/2017 3/21/2017 State Compensation Insurance Fund % /6/2017 3/16/2017 Travelers % /6/2017 3/16/2017 Travelers % /2/2017 3/21/2017 State Compensation Insurance Fund % /7/2017 3/21/2017 State Compensation Insurance Fund % /7/2017 3/21/2017 State Compensation Insurance Fund % /8/2017 3/21/2017 CorVel % /6/2017 3/16/2017 Travelers % /6/2017 3/21/2017 State Compensation Insurance Fund % /6/2017 3/21/2017 State Compensation Insurance Fund % /6/2017 3/21/2017 State Compensation Insurance Fund % /6/2017 3/21/2017 State Compensation Insurance Fund % /6/2017 3/21/2017 Tristar Risk Management % /7/2017 3/21/2017 Tristar Risk Management % /3/2017 3/21/2017 Intercare Holdings Insurance, Inc % /3/2017 3/21/2017 State Compensation Insurance Fund % /1/2017 3/21/2017 State Compensation Insurance Fund % /1/2017 3/21/2017 State Compensation Insurance Fund % /2/2017 3/21/2017 CorVel % DaisyBill 2017 CPT / l 139

140 DaisyBill 2017 CPT / l 140

141 Document Prolonged Service and Time DaisyBill 2017 CPT / l 141

142 DaisyBill 2017 CPT / l 142

143 DaisyBill 2017 CPT / l 143

144 DaisyBill 2017 CPT / l 144

145 DaisyBill 2017 CPT / l 145

146 DaisyBill 2017 CPT / l 146

147 No / Reporting Requirements DaisyBill 2017 CPT / l 147

148 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 148

149 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 149

150 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 150

151 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 151

152 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 152

153 47% Denial Rate at Day 23 procedure code units bill date of service date posted claims admin name payment amount cents expected payment cents percentage /6/2017 3/15/2017 Sedgwick Claims Management Services /1/2017 3/21/2017 Gallagher Bassett /1/2017 3/14/2017 Sedgwick Claims Management Services /1/2017 3/14/2017 State Compensation Insurance Fund /1/2017 3/16/2017 The Hartford /1/2017 3/21/2017 Liberty Mutual Insurance /1/2017 3/21/2017 Sedgwick Claims Management Services /1/2017 3/11/2017 Sedgwick Claims Management Services /1/2017 3/14/2017 State Compensation Insurance Fund /1/2017 3/9/2017 Sedgwick Claims Management Services /1/2017 3/14/2017 Sedgwick Claims Management Services /1/2017 3/21/2017 American Claims Management, Inc /1/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/16/2017 CorVel /2/2017 3/11/2017 Sedgwick Claims Management Services /2/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/16/2017 Sedgwick Claims Management Services /2/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/16/2017 Liberty Mutual Insurance /6/2017 3/15/2017 Sedgwick Claims Management Services /1/2017 3/21/2017 Gallagher Bassett DaisyBill 2017 CPT / l 153

154 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 154

155 47% Denial Rate at Day 23 procedure code units bill date of service date posted claims admin name payment amount cents expected payment cents percentage /6/2017 3/15/2017 Sedgwick Claims Management Services /1/2017 3/21/2017 Gallagher Bassett /1/2017 3/14/2017 Sedgwick Claims Management Services /1/2017 3/14/2017 State Compensation Insurance Fund /1/2017 3/16/2017 The Hartford /1/2017 3/21/2017 Liberty Mutual Insurance /1/2017 3/21/2017 Sedgwick Claims Management Services /1/2017 3/11/2017 Sedgwick Claims Management Services /1/2017 3/14/2017 State Compensation Insurance Fund /1/2017 3/9/2017 Sedgwick Claims Management Services /1/2017 3/14/2017 Sedgwick Claims Management Services /1/2017 3/21/2017 American Claims Management, Inc /1/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/16/2017 CorVel /2/2017 3/11/2017 Sedgwick Claims Management Services /2/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/16/2017 Sedgwick Claims Management Services /2/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/9/2017 Sedgwick Claims Management Services /2/2017 3/16/2017 Liberty Mutual Insurance /6/2017 3/15/2017 Sedgwick Claims Management Services /1/2017 3/21/2017 Gallagher Bassett DaisyBill 2017 CPT / l 155

156 Incorrect Payments Require Timely Second Bill Review DaisyBill 2017 CPT / l 156

157 $17.5+ Million in Second Review Payments DaisyBill 2017 CPT / l 157

158 Use the SBR-1 FORM For Appeals DaisyBill 2017 CPT / l 158

159 99358 and Incorrect Denial DaisyBill 2017 CPT / l 159

160 1. Click Second Review DaisyBill 2017 CPT / l 160

161 2. Select & Reasons DaisyBill 2017 CPT / l 161

162 3. Click Submit DaisyBill 2017 CPT / l 162

163 Second Review Electronically Sent DaisyBill 2017 CPT / l 163

164 SBR-1 Time Spent: Paper Billing vs DaisyBilling Second Review Time Required Paper Bill DaisyBill Explanation of Review (EOR) Analysis 3 0 SBR-1 Form Completed Print Form, Report, Envelope 2 0 Collate/Mail Form, Reports, Envelope 2 0 Total Second Review Time 22 Minutes 30 SECONDS DaisyBill 2017 CPT / l 164

165 Second Review Reason Library DaisyBill 2017 CPT / l 165

166 Supporting Document Library DaisyBill 2017 CPT / l 166

167 DaisyBillers Use Live Expert Help DaisyBill 2017 CPT / l 167

168 Expect Confusion and Incorrect Payments DaisyBill 2017 CPT / l 168

169 99358 / Topics Reimbursement History Current Status Code and Reimbursement CPT Guidelines 1. Prolonged Service Instructions 2. Time Requirements 3. Incompatible Codes Billing Tips Questions DaisyBill 2017 CPT / l 169

170 With Links to RESOURCE NOTEBOOK + SLIDES + VIDEO Download Resource Notebook Download Slides Watch Video DaisyBill 2017 OMFS Updates l 170

171 60 Second Survey, Promise! DaisyBill 2017 CPT / l 171

172 Work Comp Billing Conference DaisyBill 2017 OMFS Updates l 172

173 Can these codes be used for AME/QME's? Elvia More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 173

174 Can this code be used to bill review of records when a PQME appt has been cancelled and no evaluation or report has taken place? Josie More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 174

175 We are reviewing the billing of ML106 this morning and were wondering if this code is inclusive of review of records. Alexandra More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 175

176 CPT & NOT Used For Medical-Legal Evaluations Prolonged evaluation and management service before and/or after direct patient care; first hour each additional 30 minutes (List separately in addition to code for prolonged service) (Use in conjunction with 99358) (Do not report 99358, during the same month with ) (Do not report 99358, when performed during the service time of codes or 99496) DaisyBill 2017 CPT / l 176

177 AME & QME: Medical-Legal Fee Schedule ONLY DaisyBill 2017 CPT / l 177

178 California Code of Regulations, Title 8 Chapter 4.5. Division of Workers' Compensation Subchapter 1. Administrative Director--Administrative Rules Article 5.6. Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations Definitions Reimbursement of Medical-Legal Expenses Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony. DaisyBill 2017 CPT / l 178

179 What about consultations ordered by AMEs or QMEs? Alan More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 179

180 Use OMFS For Consults and Ancillary Services DaisyBill 2017 CPT / l 180

181 Used When Physician Fee Schedule Is Applicable Prolonged evaluation and management service before and/or after direct patient care; first hour each additional 30 minutes (List separately in addition to code for prolonged service) (Use in conjunction with 99358) (Do not report 99358, during the same month with ) (Do not report 99358, when performed during the service time of codes or 99496) DaisyBill 2017 CPT / l 181

182 Does this apply to dates of injury prior to 3/1/17? Laura More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 182

183 2017 Physician Fee Schedule Changes Effective Dates of Service: March 1, 2017 DaisyBill 2017 CPT / l 183

184 Would you be able to bill for services prior to March 1st, 2017? Anastasia More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 184

185 DaisyBill 2017 CPT / l 185

186 Aren t these codes considered bundled codes at this time? What is formula used for payment? Christine More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 186

187 2017 Physician Fee Schedule Changes Effective Dates of Service: March 1, 2017 DaisyBill 2017 CPT / l 187

188 DaisyBill 2017 CPT / l 188

189 So, if I spend 25 minutes reviewing outside records, that's not reimbursed? Brian More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 189

190 99358 Not Used To Report Less than 30 Minutes Of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ DaisyBill 2017 CPT / l 190

191 If the first hour is met, is there a cut off for the as well? For example if the additional time over the initial hour is 15 min or less would this be considered for reimbursement? Keith W. More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 191

192 99359 Not Used to Report Less Than 15 Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ DaisyBill 2017 CPT / l 192

193 If medical record review is 1 hour and 45 minutes, how many times would we report each code? Shirley More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 193

194 99358 / Time Card Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ :30 1:44 $ $71.96 $ :45 1:59 $ $ $ :00 2:14 $ $ $ :15 2:29 $ $ $ :30 2:44 $ $ $ :45 2:59 $ $ $ :00 3:14 $ $ $ :15 3:29 $ $ $ :30 3:44 $ $ $ :45 3:59 $ $ $ :00 4:14 $ $ $ :15 4:29 $ $ $ DaisyBill 2017 CPT / l 194

195 How often can we bill for 99358? Livy More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 195

196 What is the maximum time allowed per day to bill for records review? plus only cover 1.5 hours. Keith B. More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 196

197 99358 Used Only Once Per Day Time Requirements 2. Code is used to report a. the first hour of prolonged service i. on a given date ii. regardless of the place of service. b. It should be used only once per date. 1 DaisyBill 2017 CPT / l 197

198 99358 Maximum 1 Unit Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ :30 1:44 $ $71.96 $ :45 1:59 $ $ $ :00 2:14 $ $ $ :15 2:29 $ $ $ :30 2:44 $ $ $ :45 2:59 $ $ $ :00 3:14 $ $ $ :15 3:29 $ $ $ :30 3:44 $ $ $ :45 3:59 $ $ $ :00 4:14 $ $ $ :15 4:29 $ $ $ DaisyBill 2017 CPT / l 198

199 99359 No Maximum Units Listed Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ :01 1:14 $ $0.00 $ :15 1:29 $ $71.96 $ :30 1:44 $ $71.96 $ :45 1:59 $ $ $ :00 2:14 $ $ $ :15 2:29 $ $ $ :30 2:44 $ $ $ :45 2:59 $ $ $ :00 3:14 $ $ $ :15 3:29 $ $ $ :30 3:44 $ $ $ :45 3:59 $ $ $ :00 4:14 $ $ $ :15 4:29 $ $ $ DaisyBill 2017 CPT / l 199

200 Could a physician assistant bill these codes? Patricia More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 200

201 Beyond Usual Service Time & Do Not Report Face-to-Face Time Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same ii. session of an evaluation and management service, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and b. is beyond the usual physician or other qualified health care professional service time. DaisyBill 2017 CPT / l 201

202 Non-Physician Providers Non-Physician Practitioner (NPP) - Payment Methodology Non-Physician Practitioner (NPP) - "Incident To" Services Qualified Non-Physician Anesthetist Services. DaisyBill 2017 OMFS Updates l 202

203 DaisyBill 2017 OMFS Updates l 203

204 Easy Regulation References DaisyBill 2017 OMFS Updates l 204

205 Can the provider be paid for reviewing his own records? Tarell More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 205

206 Includes Review of OTHER Service Records Prolonged Service Instructions 2. Prolonged service is to be reported in relation to other physician or other qualified health care professional services, a. including evaluation and management services at any level. DaisyBill 2017 CPT / l 206

207 Can we bill 15 minute increments? Jeff More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 207

208 Instructions: 15 Minutes Record Review DaisyBill 2017 CPT / l 208

209 What kind of documentation is required for these services? Judy More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 209

210 For review of records do we have to be specific on what records? Angie More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 210

211 What is the shortest but best way to document the time elements for our providers? Kellie More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 211

212 No / Reporting Requirements DaisyBill 2017 CPT / l 212

213 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 213

214 Can we bill review of medical records on initial consult and permanent and stationary? Connie More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 214

215 A provider spends 30 minutes reviewing records for a P&S report, is that still billable? Michele More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 215

216 Includes Review of OTHER Service Records Prolonged Service Instructions 2. Prolonged service is to be reported in relation to other physician or other qualified health care professional services, a. including evaluation and management services at any level. DaisyBill 2017 CPT / l 216

217 Must Relate to Face-to-Face Care Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care. i. has occurred or ii. will occur, and DaisyBill 2017 CPT / l 217

218 Must Relate to Ongoing Patient Management Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care i. has occurred or ii. will occur, and b. ongoing patient management. DaisyBill 2017 CPT / l 218

219 Can these codes be billed on same day as office visit? Daphne More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 219

220 Neither Face-To-Face Time During E/M Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same session of an evaluation and management service, nor DaisyBill 2017 CPT / l 220

221 Will UR apply to the use of and 99359? Sarah More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 221

222 Do we need to request authorization first to bill for these codes? Adam More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 222

223 Utilization Review Decides Treatment Recommendations Labor Code (a) For purposes of this section, utilization review means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, as defined in Section , prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Section DaisyBill 2017 CPT / l 223

224 Utilization Review Standards - Definitions - On or After January 1, 2013 (t) Request for authorization means a written request for a specific course of proposed medical treatment. Request for Authorization for Medical Treatment DaisyBill 2017 CPT / l 224

225 Must Relate to Face-To-Face Care Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care. i. has occurred or ii. will occur, and DaisyBill 2017 CPT / l 225

226 Beyond the Usual Service Time Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same ii. session of an evaluation and management service, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and b. is beyond the usual physician or other qualified health care professional service time. DaisyBill 2017 CPT / l 226

227 Utilization Review Standards - Definitions - On or After January 1, 2013 (t) Request for authorization means a written request for a specific course of proposed medical treatment. Request for Authorization for Medical Treatment DaisyBill 2017 CPT / l 227

228 How do we correctly pay for UR authorization requests? Previously providers would use to bill for these requests. What is the correct way to handle this now? Rita More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 228

229 CPT Reimbursement By Report (BR) DaisyBill 2017 CPT / l 229

230 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 230

231 99358 Not Used to Report Less Than 30 Minutes of Prolonged Service Start Hour:Minute End Hour:Minute Unit Reimbursement Units Unit Reimbursement Total Reimbursement 0 0:29 $ $0.00 $0.00 0:30 1:00 $ $0.00 $ DaisyBill 2017 CPT / l 231

232 Can be used along with 99354? Ashlee More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 232

233 DaisyBill 2017 CPT / l 233

234 Incompatible Codes 1. Do not report 99358, for time spent in a. care plan oversight services (99339, 99340, ), b. anticoagulant management ( ), c. medical team conferences ( ), d. on-line medical evaluations (99444), or e. other non-face-to-face services codes that have a published maximum time (eg, telephone services). 2. Do not report 99358, during the same month with Do not report 99358, when performed during the service time of codes or DaisyBill 2017 CPT / l 234

235 Can & be billed alone with no other codes? Amanda More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 235

236 DaisyBill 2017 CPT / l 236

237 Can we bill using the same date of service as Doctor face to face with Patient on ONE submission on DaisyBill????? Rosanna More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 237

238 DaisyBill 2017 CPT / l 238

239 Do we need to add a modifier when billing at same time as E&M codes? Ann More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 239

240 Adopted and Adapted Medicare Rules Status Codes Professional Component (PC)/Technical Component (TC) Indicator Coding; Current Procedural Terminology, Fourth Edition Evaluation and Management: Coding - New Patient; Documentation Consultation Services Coding - Use of Visit Codes Correct Coding Initiative. DaisyBill 2017 CPT / l 240

241 No Modifier Required With E/M Codes DaisyBill 2017 CPT / l 241

242 Is the billing only for first time referrals? Are secondary treating physicians eligible to bill for the 99358/99359 codes? Marissa More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 242

243 Must Relate to Face-To-Face Care Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care i. has occurred or ii. will occur, and DaisyBill 2017 CPT / l 243

244 Must Relate to Ongoing Patient Management Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care i. has occurred or ii. will occur, and b. ongoing patient management. DaisyBill 2017 CPT / l 244

245 Can you please clarify how these codes differ from other reporting codes such as & WC007? Therese More questions? Contact Sarah at: or DaisyBill 2017 CPT OMFS Updates / l 245

246 DaisyBill 2017 CPT / l 246

247 SB 863 RBRVU-Based Physician Fee Schedule Services Rendered as of January 1, 2014 Table A DaisyBill 2017 CPT / l 247

248 99080 Not Reimbursable Effective 1/1/2014 DaisyBill 2017 CPT / l 248

249 California Specific Forms and Reports California Specific Codes Description WC001 WC002 WC003 WC004 Doctor's First Report of Occupational Illness or Injury (Form 5021) Treating Physician's Progress Report Primary Treating Physician s Permanent and Stationary Report (Form PR-3) Primary Treating Physician s Permanent and Stationary Report (Form PR-4) WC005 WC007 WC008 Psychiatric Report requested by the WCAB or the Administrative Director, other than medical-legal report. Consultation Reports Requested by the Workers Compensation Appeals Board or the Administrative Director Chart Notes DaisyBill 2017 CPT / l 249

250 Update Table (d) Services Rendered On or After 3/1/2017. Documents listed in the following table are incorporated by reference and will be made available upon request to the Administrative Director. Code California Specific Codes Effective 3/1/ Reimbursement Description WC001 $0.00 Not reimbursable WC002 $12.29 WC003 $39.89 for first page $24.54 each additional page. Maximum of six pages absent mutual agreement WC004 $39.89 for first page $24.54 each additional page. Maximum of seven pages absent mutual agreement WC005 $39.89 for first page $24.54 each additional page. Maximum of six pages absent mutual agreement WC007 $39.89 for first page $24.54 each additional page. Maximum of six pages absent mutual agreement WC008 $39.89 for first page $24.54 each additional page. Maximum of six pages absent mutual agreement WC009 $10.58 for up to the first 15 pages. $0.25 for each additional page after the first 15 pages WC010 $5.29 per x-ray WC011 $10.58 per scan WC012 $0.00 No Fee Prescribed / Non Reimbursable absent agreement DaisyBill 2017 OMFS Updates l 250

251 WC007 Consultation Report Requested by WCAB or AD or AME or QME AME QME DaisyBill 2017 CPT / l 251

252 Beyond the Usual Service Time Prolonged Service Instructions 1. Codes and are used when a prolonged service is provided that a. is neither i. face-to-face time in the office or outpatient setting during the same ii. session of an evaluation and management service, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service, and b. is beyond the usual physician or other qualified health care professional service time. DaisyBill 2017 CPT / l 252

253 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 253

254 Can providers use the prolong service code for UR appeal letters? If not, are UR appeal letters reimbursable under a different code? No other service is provided at this timestrictly writing an appeal letter. Tracey More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 254

255 Appeal Letters NOT Reimbursable DaisyBill 2017 CPT / l 255

256 Do these codes only work in conjunction with a patient visit? Can you use this codes to bill for time on UR peer-to-peer calls? Suzanne More questions? Contact Sarah at: smoray@daisybill.com or DaisyBill 2017 CPT OMFS Updates / l 256

257 Must Relate to Face-To-Face Care Prolonged Service Instructions 4. However, prolonged service must relate to a. a service or patient where (face-to-face) patient care. i. has occurred or ii. will occur, and DaisyBill 2017 CPT / l 257

258 99358 / Supporting Documentation Patient Name: DOS: XX:XX hours:minutes of non-face-to-face prolonged service provided that relates to (face-to-face) care that has or will occur and ongoing patient management, including one or more of the following: Reviewed records from other physicians or other health care professional services, including one or more of the following: other medical records and diagnostic / radiology study results Reviewed correspondence reviewed from one or more of the following: applicant and/or defense counsel, insurance carrier, utilization review Reviewed a job analysis, an evaluation of ergonomic status, work limitations, or work capacity Preparation of RFA requesting patient treatment Preparation of requested report Discussed patient care with employer s nurse case manager Telephone call with employer s utilization review for authorization of requested treatment Other DaisyBill 2017 CPT / l 258

259 CPT & Medical Team Conference Medical team conferences include face-to-face participation by a minimum of three qualified health care professionals from different specialties or disciplines (each of whom provide direct care to the patient), with or without the presence of the patient, family member(s), community agencies, surrogate decision maker(s) (eg, legal guardian), and/or caregivers(s). DaisyBill 2017 CPT / l 259

260 Billaroo! Topics Billing Timelines Payment Data Penalty and Interest Second and Independent Bill Review Requests for Authorization Medical Provider Networks Utilization Review Medical-Legal And more DaisyBill 2017 CPT / l 260

261 DaisyBill 2017 CPT / l 261

262 DaisyBill 2017 CPT / l 262

263 Contact Us! Sarah Moray DaisyBill 2017 CPT / l 263