We get it. Getting paid accurately is difficult. And we understand that payment issues and delays can wreak havoc on your cash flow and cause extra work. Pinnacol is here to help. We have certified coders on staff who can help you navigate the unique aspects of workers’ compensation billing.
The Division of Workers’ Compensation of Colorado (DOWC) sets the billing requirements for all workers’ compensation cases in Colorado.
Rule 18 states CPT codes are based on the code set for the prior year and the relative value of each code is based on RBRVS using the Medicare standard from the prior year. For workers' compensation in 2021, the code set to be used for billing is from 2020.
Significant changes were made to the evaluation and management codes approved by CMS in 2021. In Colorado, these changes were not adopted in 2021 for workers' compensation billing.
For medical services to be reimbursed, the Centers for Medicare and Medicaid Services (CMS) state medical necessity is the overarching criterion for payment. Medical necessity is defined as the activities justified as reasonable, necessary and/or appropriate based on evidence-based clinical standards of care.
The nature of the presenting problem is considered in time documentation. Time documentation should be specific and include details of the counseling and the injured worker's participation in the discussion and counseling.
Unsupported or under-documented codes may be subject to denial or audit.
The three key components when selecting a level of E&M service are:
Time for counseling and/or coordination of care
- Time cannot always determine the level of service.
- Time can determine the level of service only if you submit patient-specific documentation for the visit that more than 50 percent of a physician’s time was spent face to face with the patient in counseling and/or coordinating care.
- Counseling should include documenting the discussion/dialogue of what the patient and physician said, not just what they discussed. Documentation should include specifics and notations of the patient’s understanding of the counseling — e.g., return-to-work discussions, pharmaceutical management (drug side effects and potential of addiction/problems).
- Documentation must support the amount of time spent with the patient.
- Coordination of care requires the physician to call another health care provider (outside of the clinic) to discuss the patient’s diagnosis and/or treatment, or the physician to visit or call the employer to ensure the patient’s safe return to work.
- Documentation must support the amount of time spent on coordination of care.
E&M level with closing report
- A final office visit billed with the closing report should rarely be billed as a moderate or high level E&M visit. If the injured worker is determined to be at maximum medical improvement, it is likely the injury is sufficiently improved without worsening problems or needing further workup.
- E&M guidelines indicate a level 99212 or 99213 would be appropriate for the medical decision-making for an established problem (stable or improved) with minimal or low risk and no further discussion or data review of labs, imaging or test results.
If you have any questions, Pinnacol’s provider medical billing auditors would be happy to assist you. Please call the Medical Payments Team and Payment Appeals department at 303.361.4940 or email firstname.lastname@example.org (fax: 303.361.5940).