Section 418.10202. Evaluation and management services.

(1) The evaluation and management   procedure  codes  from "Current Procedural Terminology, CPT®", as  adopted  by  reference  in   R 418.10107,  shall be used on  the  bill   to  describe   office   visits, hospital  visits,    and  consultations.   These  services are divided into subcategories of new patient and established patient visits. The services are also classified according to complexity of the services. For the purposes of workers' compensation, a treating practitioner, for each new case or date of injury, shall use a new patient visit to describe the initial visit. A treating physician may not use procedures 99450- 99456 to bill for services provided to an injured worker. When a practitioner applies a hot or cold pack during the course of  the office visit, the carrier shall not be required to reimburse this as a separate charge.

(2)   Minor medical and surgical supplies routinely used by the practitioner or health care organization in the office visit shall  not  be  billed separately. The provider may bill separately for supplies, or other services, over and above those usually incidental to the evaluation and management service using appropriate CPT® or HCPCS procedure codes.

(3)   When a specimen is obtained and  sent  to   an  outside  laboratory, the provider may add 99000 to the bill to describe the handling/conveyance of the specimen. The carrier shall reimburse $5.00 for this service in addition to the evaluation and management service.

(4)     Appropriate procedures from "Current Procedural Terminology, CPT®" or "Medicare's Level II Codes, HCPCS" may be billed in addition to the evaluation and management   service.  If  an  office  visit   is  performed outside of the provider's normal business

hours, the provider may bill the add on procedure code, 99050, describing an office visit performed after hours or on Sundays or holidays and  shall  be  reimbursed   $12.00  in addition to the evaluation and management. The carrier shall only be required to reimburse the miscellaneous add-on office procedures when the services are performed outside of the provider's normal hours of business.

(5)    A procedure that is normally part of an examination or evaluation shall not be unbundled and billed independently. Range  of  motion  shall not  be reimbursed as  a separate procedure in addition to the evaluation and management service unless  the procedure is medically necessary and appropriate for the injured worker's condition and diagnosis.

(6)   The maximum allowable payment  for  the   evaluation  and  management service shall be determined by multiplying the relative value unit, RVU, assigned to the procedure code, times the conversion factor listed in  the reimbursement section of these rules.

(7)    The level of an office visit or other outpatient visit for the evaluation and management of a patient is not guaranteed and may change from session to session. The  level of service shall be consistent with the type of presenting complaint and supported by documentation in the record.

(8)   When a provider bills for an evaluation and management service, a separate drug- administration charge shall not be reimbursed by the carrier, since this is considered a bundled service inclusive with the visit.The drug administration charges may be billed and paid   when   the evaluation  and management service is not performed and billed for  a    date of service. The provider shall bill the medication separate and be paid in accordance with the reimbursement section of these rules. The  provider shall use the  NDC  or national drug code for the specific drug and either 99070, the unlisted drug and supply code or the specific J- code listed in HCPCS to describe the medication administered.

(9)   When a provider administers a vaccine during an evaluation and management service, both the vaccine and the administration of the  vaccine are billed as separate  services in  addition  to   the  evaluation   and management  visit according to language in CPT®. Both the administration of the vaccine and the vaccine shall be  reimbursed   in  accordance   with the reimbursement provisions of these rules in addition to the visit.

(10)   Procedure code 76140, x-ray consultation, shall not be paid to the provider in addition to the evaluation and management service, to review x-rays taken elsewhere. The carrier shall not pay for review of an x-ray by a practitioner other than the radiologist providing the written report or the practitioner performing the complete radiology procedure.

History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2004 AACS; 2007 AACS.