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CALIFORNIA WORKERS COMPENSATION COLLECTIONS
PUBLICATIONS, EDUCATION AND INFORMATION FOR TREATMENT AND
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California Workers' Comp
URINE DRUG SCREEN    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
ISSUE IN DISPUTE Provider is dissatisfied with denial of codes 72070 and 72110
ISSUE IN DISPUTE The reimbursement of CPT 17999 for date of service
1/31/2014
ISSUE IN DISPUTE:  Provider is dissatisfied with down -coding of 99204 to 99203
and reimbursement for multiple injured workers with separate dates of service.
ISSUE IN DISPUTE : Provider seeking remuneration for the following
medications and
compound medications: NDC 38779187105, NDC 38779273904 , NDC
38779039503,
NDC 38779038803, NDC 38779008202 , NDC 00591367105, NDC
76218121901,
NDC53746011005 and NDC 60505006601 dispensed to Injured Worker on
05/05/2014
ISSUE IN DISPUTE: Provider seeking remuneration for 97530-59 x 4 Units
Physical
Medicine services performed on 02/26/2014–03/05/2014
ISSUE IN DISPUTE :Provider seeking additional remuneration for WC004
PR4 report
up to 15 pages.Upon second bill review, no additional payment for WC004
was issued
ISSUE IN DISPUTE: Provider seeking full remuneration for 82145,
80154,82520 ,83925,83925-59,82145-59 Laboratory services performed on
04/02/2014
ISSUE IN DISPUTE: Provider is dissatisfied with reimbursement of DRG 454,
Inpatient
Services.
ISSUE IN DISPUTE: Provide r seeking remuneration for Lab Services CPT
Codes, 82205, 82520, 83840, 83992 , 83992, 83925, 83925 - 59, 82145 and
82055 (G4034) for date of service 01/28/2014
CT SCAN = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
2015 Book on Authorization, Utilization Review With 1000 IMR Decisions to Show Why
Treatment is not Being Authorized. Not only did the formalities of the WCAB and the IBR
process change but also the detail requirements in the request for authorization and to get UR
reversal by IMRs. A missed word and a left out explanation, a lack of documents, changes if the
treatment is authorized or if reversed and certified by IMR
Also receive 1500 IBR Decisions summarized
and indexed
EMG/NCS   = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
SLEEP EVALUATION WITH TESTING= Guidelines = Elements Required in Documentation =Common
Errors= Authorized
8 WEEK 24 LESSON COURSE  IN WORK COMP TREATMENT AND
COLLECTIONS for $325.00 (INDIVIDUAL OR ENTIRE STAFF)
INTRATHECAL PUMP = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
8 WEEK 24 LESSON COURSE  IN WORK COMP
TREATMENT AND COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE STAFF)
MANIPULATION UNDER ANESTHESIA = Guidelines = Elements Required in Documentation =Common
Errors= Authorized
6 Month  24 LESSON
COURSE  IN WORK COMP
TREATMENT AND
COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE
STAFF)
ISSUE IN DISPUTE: Provider seeking full remuneration for  99499 Unlisted Evaluation
and Management services representing Functional Restoration Program for service dates
04/07/2014 04/11/2014.
ISSUE IN DISPUTE: Provider questioning Claims Administrator’s re-coding of 99214
Evaluation and Management service provided to Injured Worker on 01/29/214 and $0.00
reimbursement for 99070 -NDC#68453095010 submitted charge.
AMBIEN = Guidelines = Elements Required in Documentation =Common Errors= Authorized
ANAPROX  = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
ATIVAN = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
CAPSAICIN 0.025%, FLURBIPROFEN 20%, TRAMADOL
10%,MENTHOL 2%, CAMPHOR 2
%= Guidelines = Elements
Required in Documentation =Common Errors= Authorized
CARAFATE = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CARISOPRODOL = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHIATRY VISITS   = Guidelines = Elements Required in Documentation =Common Errors= Authorized
CELEBREX= Guidelines = Elements Required in Documentation =Common Errors= Authorized
CLONAZEPAM  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
COLACE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
PSYCHOTHERAPY      = Guidelines = Elements Required in Documentation =Common Errors= Authorized
COMPOUND CREAM= Guidelines = Elements Required in Documentation =Common Errors= Authorized
SKILLED NURSING  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
COMPOUND GABAPENTIN POWDER= Guidelines = Elements Required in Documentation =Common
Errors= Authorized
CYCLOBENZAPRINE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
CYMBALTA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
TRIGGER POINT AND TENDER SPOT INJECTIONS = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
DENDRACIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
LUMBAR FUSION W/ INSTRUMENTATION, USE
AUTOGRAFT AND/OR ALLOGRAFT:= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
DIAZEPAM (VALIUM)= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DICLOFENAC  = Guidelines = Elements Required in Documentation =Common Errors= Authorized
DICOPANOL (DIPHENHYDRAMINE)= Guidelines = Elements Required in Documentation =Common
Errors= Authorized
DICYCLOMINE HCL 2= Guidelines = Elements Required in Documentation =Common Errors= Authorized
DILAUDID= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CARDIAC CLEARANCE   = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
CARDIOLOGY CONSULT = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
CONSULT WITH PAIN MANAGEMENT = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
EKG = Guidelines = Elements Required in Documentation
=Common Errors= Authorized  EKG
ELECTROENCEPHALOGRAPHY (EEG) = Guidelines = Elements Required in Documentation =Common
Errors= Authorized
ELECTROMYOGRAM    = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
GROUP THERAPY = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
HOME HEALTH CARE = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
NEUROLOGICAL CONSULTATION   = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
NEUROSTIMULATION THERAPY = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
DME Varies  = Guidelines = Elements Required in Documentation =Common Errors= Authorized  EKG
REFERRAL TO NEUROSURGEON = Guidelines =
Elements Required in Documentation =Common
Errors= Authorized
NUCLEAR STRESS TEST = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
OCCUPATIONAL THERAPY= Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
PAIN MANAGEMENT    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PLATELET RICH PLASMA INJECTION  = Guidelines = Elements Required in Documentation =Common
Errors= Authorized
PNEUMATIC INTERMITTENT COMPRESSION   = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
INTERMITTENT COMPRESSION DEVICE= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
PRE-OP TESTING = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHE TREATMENT= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHIATRIC MEDICATIONS MANAGEMENT   = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
PSYCHOLOGICAL EVALUATION = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
PSYCHOPHARMACOLOGY MANAGEMENT    =
Guidelines = Elements Required in Documentation
=Common Errors= Authorized
SPINAL SURGICAL CONSULTATION= Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
DEBRIDEMENT OF THE RIGHT SHOULDER =
Guidelines = Elements Required in Documentation
=Common Errors= Authorized
SHOULDER OPEN ROTATOR CUFF REPAIR = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
KNEE ARTHROSCOPY= Guidelines = Elements
Required in Documentation =Common Errors=
Authorized
SHOULDER ARTHROSCOPY = Guidelines = Elements Required in Documentation =Common Errors=
Authorized
WORK HARDENING VISITS = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
DUEXIS= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
EFFEXOR= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FENTANYL= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FEXMID = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FLECTOR= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FLEXIRIL= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FLURBIPROFEN CREAM,= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
FLURIFLEX (FLURBIPROFEN/CYCLOBENZAPRINE 15/10
%) CREAM 1= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
GABAPENTIN= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
HYDROCODONE= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
IBUPR= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
KETOPROFEN= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
KLONOPIN= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
LIDOCAINE PAD= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
LIDODERM PATCH= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
LINZESS= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
LORTAB ELIXIR= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
LYRICA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MELOXICAM (MOBIC)= Guidelines = Elements Required in Documentation =Common Errors= Authorized
METHODERM OINTMENT= Guidelines = Elements Required in Documentation =Common Errors=
Authorized
MENTHODERM= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MORPHINE SULFATE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
MS CONTIN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NABUMETONE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NAPROXEN= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NOCTURNAL OBSTRUCTIVE AIRWAY ORAL APPLIANCE / DECAY OR FRACTURED TEETH=
Guidelines = Elements Required in Documentation =Common Errors= Authorized
NORCO= Guidelines = Elements Required in Documentation =Common Errors= Authorized
NUCYNTA= Guidelines = Elements Required in Documentation =Common Errors= Authorized
OMEPRAZOLE= Guidelines = Elements Required in Documentation =Common Errors= Authorized
ONDANSETRON ODT = Guidelines = Elements Required in Documentation =Common Errors= Authorized
From Program: Second Review and IBR Response:    63047-62-22 &
63048-62-22 x2 units Additional remuneration for Co-Surgeon Services
relating to 63047-62-22 Laminectomy, facetectomy and foraminotomy
(unilateral or bilateral with decompression of spinal cord, cauda equina
and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral
segment; lumbar & add -on code 63048-62-22 Laminectomy, facetectomy and
foraminotomy (unilateral or bilateral with decompression of spinal cord,
cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]),
single vertebral segment; each additional segment, cervical, thoracic, or
lumbar (list separately in addition to code for primary procedure)x 2 Units,
performed on 08/29/2014
From Program: Second Review and IBR Response:    IBR unable to
calculate a rate of reimbursement for 4 ounces of Keratek Gel as the
NDC# provided appears to be invalid and the submitted invoice does not
indicate a per bottle weight of the ’24 bottles’ reflected. 99070  NDC#
54162054004 QTY 113
From Program 2015 Papers Articles: Adjusters-Liens, Who are They, What Did They Do with The
Old Adjusters
From Program: Second Review and IBR Response:    As a contractual
agreement between the Provider and the Claims Administrator does not
exist; OMFS will be utilized to calculate reimbursement.•Based on
information reviewed, additional reimbursement for codes 99213 and
WC002 is warranted
From Program: Second Review and IBR Response:    96101 -Psychological
testing (includes psychodiagnostic assessment of emotionality,
intellectual abilities, personality and psychopathology, eg, MMPI,
Rorschach, WAIS), per hour of the psychologist's or physician's time, both
face-to-face time administering Tests to the patient and time interpreting
these test results and preparing the report
From Program: Second Review and IBR Response:    J2278-KD NDC
418860072010 documentation indicates Prialt 100 mcg/1 ml x 6 viles of
single dose ampule administered to Intrathecal Pain Pump $3,960.00
2015 Posted Articles
From Program 2015 Papers Articles:WC:Collection Paper vs. Providers'
Receivables 10 Cents on The Dollar?
From Program 2015 Papers Articles: We Fooled Providers for So Long,
They Now Turn a Deaf Ear to Us--Help.
From Program 2015 Papers Articles: (PBM), DISCOUNTED PAYMENTS FOR PHARMACY,
BIGGEST FRAUD SINCE PPOS OR ?
From Program 2015 Papers Articles: WC: Providers Have Always Been
Underpaid, Just No One Ever Told Them
From Program 2015 Papers Articles: determination of Medical-Legal Dispute, Interpreter, Copy Service,
From Program 2015 Papers Articles: WC: Receivables= Strategic,
Tactical,  Operational & Contingency Planning
From Program 2015 Papers Articles: WC: Reading Laws Incorrectly,
Putting Receivables on a Path of Default
From Program 2015 Papers Articles: Chiropractic Beyond 24 w/o Surgery
/ When Necessary for Wrist and Hand
From Program 2015 Papers Articles: WC: Why Some Providers are
Cheating Themselves out of Payments Due
From Program 2015 Papers Articles :WC: Frauds That Survived SB 863, PPOs, MPNs,
Prescription Drug Cards
From Program 2015 Papers Articles: WC: The Power Of Requests for 2nd
Bill Review and Notice to File Lien
From Program 2015 Papers Articles: UR Certification, Same as Authorized,
PBM, MPN, PPO Denied Body Part?
From Program 2015 Papers Articles: The Day of a Work Comp Collector,
That What We Perceive No Longer True
From Program 2015 Papers Articles: Mythical Search For The Answer to
94% Authorized Treatment/ Services
From Program 2015 Papers Articles: WC: Treatment / Collection Disputes
The One Thing That Can No Longer be Glossed Over
Program: Objections and Responses As Determined by
decisions : ML 104:Claims Administrator reimbursed $2636.72
indicating on the Explanation of Review “In accordance with the
California Official Medical Fee Schedule, Section 9789.15.1, this
service was reduced due to the non-physician practitioner (NPP)
payment methodology. (MNPR)  --incorrect
Program: Objections and Responses As Determined by decisions
:     claims administrator denied code indicating on the Explanation of
Review “Service/item included in the value of other services per CCI
edits. Related service could be on separate bill.” incorrect-    Provider
billed code 96101-59 along with 99205.
Program: Objections and Responses As Determined by
decisions :Claims administrator reimbursed $59.12 indicating on the
Explanation of Review “The number of units billed for this
procedure code exceeds the reasonable number usually provided in a
given setting as defined within the Medically Unlikely Edits (MUEs)
which is published and maintained by the Centers for Medicare and
Medicaid Services” This denial is incorrect as these are lab charges
not physician charges.
Program: Objections and Responses As Determined by
decisions : Claims Administrator reimbursed $113.34 of billed
amount $1396.80 indicating on the Explanation of Review “Charge
for pharmaceuticals exceed the fees established by the fee
schedule/UCR rates” Compound Medication Claim Administrator
Incorrect
Program: Objections and Responses As Determined by
decisions : Provider seeking remuneration for the following
Ambulatory Services performed on 11/03/2014: 64635-SG $860.00;
64635 -SG-50 $430.00;64636-SG $568.00; & 64636-SG-50 $568.00.
•Claims Administrator denial rational: “Reimbursement for this
service is not payable to Ambulatory Surgical Centers  --- Incorrect
Program: Objections and Responses As Determined by
decisions :The Claims Administrator did not reimburse the Provider
based on the Multiple Endoscopy guidelines as described in the
OMFS Physician Fee Schedule Regulation effective January 1, 2014.
Therefore, reimbursement of code 29881 is warranted.  
Program: Objections and Responses As Determined by
decisions :G0260-LT  Provider billed the disputed CPT codes on a
UB04, bill type 831 for date of service 10/02/2014. •Claims
Administrator reimbursement rational: “Service not paid under
outpatient facility fee schedule  - incorrect
Program: Objections and Responses As Determined by decisions : 95913
nerve conduction studies; 13 or more studies, performed on 9/26/2014. •Claims
Administrator denied the service with the following rational: “The documentation
does not support the level of service billed. Reimbursement was made for a code
that is supported by the Documentation  submitted with the billing .” Reimbursed
as 95912 Nerve conduction studies; 11-12 studies
Program: Objections and Responses As
Determined by decisions :Claims administrator
down coded ML 104 to ML 102 indicating on the
Explanation of Review “Documentation doesn’t
support the level of services” and “Lower ML 104
to ML 102.
Program: Objections and Responses As Determined by decisions : Provider
seeking full remuneration for 99214 Evaluation and Management Services
performed on 10/27/2014.•Claims Administrator applied reimbursement relating to
CPT 99213 with the following rational: “The documentation doesn’t support the
level of service billed. Reimbursement was made for a code that is supported by
the description and documentation submitted with the billing
Program: Objections and Responses As Determined by decisions : 63012-59
and 63047-59 for date of service 4/7/2014.•Claims Administrator denied both
codes indicating on the Explanation of Review “National Correct Coding Initiative
Edit–either mutually exclusive of or integral to another service performed on the
same day”; “The benefit for this service is included in the payment/allowance for
another service/procedure that has already been adjudicated”and “No separate
payment was made because the value of the service is included within the value of
another service performed on the same day.”
Program: Objections and Responses As Determined by decisions :
Remuneration for Inpatient Hospital DRG 0470 for dates of service 09/14/2014
–09/20/2014.• Claims Administrator based reimbursement with the following
rational: “PPO Amount.”•Contractual agreement not available for IBR
Program: Objections and Responses As Determined by decisions :ISSUE
IN DISPUTE: Provider is dissatisfied with denial of code 90837 for multiple
dates of service. •Claims Administrator denied codes indicating on the
Explanation of Review “CPT code submitted is based on service time and
documentation does not support the time spent on this procedure.” • -
Psychotherapy, 60 minutes with patient and/or family member
Program: Objections and Responses As Determined by decisions :
Provider is billing their services as outpatient services in which the
outpatient ruling does not list long term care hospitals as being exempt
from the fee schedule. They are exempt from IPPS, but not
OPPS in which case the OPPS rules would still apply to this bill.
Additionally, the provider is within the PPO network and subject to
further reductions.”
Program: Objections and Responses As Determined by decisions
:ISSUE IN DISPUTE: Denial of CPT code 63650-59
Program: Objections and Responses As Determined by decisions :ISSUE
IN DISPUTE: Provider disputing reimbursement for ML104, 73110, 72110,
73562, 73030 and 72040 services performed on 03/27/2014. •Claims
Administrator ML104 reimbursement rational: “FCE Not Requested,” and
“Not Authorized.” •FCE “Functional Capacity
Program: Objections and Responses As Determined by decisions :
Denial of code 99199 Special Report.
Program: Objections and Responses As Determined by decisions :
Denial of ML 104-94 - $10,687.50 ordered paid
Program Files Medical Necessity RFA:  Right Elbow Cubital
Tunnel Release: Overturned
Program Files Medical Necessity RFA: Left knee arthroscopy
with partial meniscectomy, possible chondroplasty and possible
removal of loose bodies: Overturned
Program Files Medical Necessity RFA: Lumbar ESI at L5-S1:
Overturned
Program Files Medical Necessity RFA: Computed
Tomography (CT) of the Cervical Spine: Overturned
Program Files Medical Necessity RFA: Physical Therapy (3x
week/6 weeks, 18 Total Visits: Overturned
Program Authorization UR Denials Overturned by IMR:
Psychotropic therapy, once per week for one week: Overturned
Program Authorization UR Denials Overturned by IMR:
TWELVE (12) PHYSIOTHERAPY VISITS :Overturned
Program Authorization UR Denials Overturned by IMR: initial
Ortho Consult for Left Elbow and Left Wrist: Overturned
Program Authorization UR Denials Overturned by IMR: Pain
management consultation: Overturned
Program Authorization UR Denials Overturned by IMR:
Clonidine 0.1mg #90: Overturned
Program Authorization UR Denials Overturned by IMR:
MRI Arthrogram Right Ankle:Overturned
Program Authorization UR Denials Overturned by IMR: Pain
Management Consultation:Overturned
Program Authorization UR Denials Overturned by IMR:
POST-OP PHYSICAL THERAPY FOR THE RIGHT
SHOULDER 3 X 4:Overturned
Program Authorization UR Denials Overturned by IMR:
Follow-up internal medicine evaluation: Overturned
Program Authorization UR Denials Overturned by IMR
Neurosurgical consult: Overturned
Program Authorization UR Denials Overturned by IMR
Retrospective request for Norco 10/325 mg #60
DOS:1/24/14:Overturned
Program Authorization UR Denials Overturned by IMR: Right
Shoulder Arthroscopic Rotator Cuff Repair with Decompression:
Overturned
Program Authorization UR Denials Overturned by IMR:
Med panel to evaluate hepatic and renal function: Overturned
Program Authorization UR Denials Overturned by IMR:
Psychological Evaluation: Overturned
Program Authorization UR Denials Overturned by IMR: Left
Knee Video Arthroscopy, Medial Meniscectomy : Overturned
Program: Objections and Responses As Determined by
decisions : (E/M) service by the same physician on the day of a
procedure:  
New:

DRG 491 PPO Issue

Tuesday, June 30, 2015

7:31 PM

 

 

ANALYSIS AND FINDING  Based on review of the case file the following is noted:

·

ISSUE IN DISPUTE: Provider seeking full remuneration for Inpatient Hospital Services DRG 491

Back & Neck Proc.Exc. spinal fusion W/O CC/MCC performed 09/08/2014 -09/09/2014.

·

Claims Administrator reimbursement rational: “No further reimbursement was made as the maximum allowance has been reached for this admission. Labor Code 5307.1”·

§9789.21. (o) "Inpatient Hospital Fee Schedule maximum payment amount" is that amount determined by multiplying the DRG weight x hospital composite factor x 1.20 and by making any adjustments required in Section 9789.22 (G)(2).

·

DRG 491 is not listed in Section 9789.22 (G)(2) for additional fees.

·

Contractual Agreement Not Available for IBR. As such, 100% OMFS will be utilized to

calculate payment pursuant to §9789.21.The table below describes the pertinent claim line information

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2015_10-100/CB15-0000014.pdf>

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

DRG 491

$65,218.79

$1,425.00

$14,803.38

1

 

$14,239.99

Additional awarded $12,814.99

 

 

Machine generated alternative text: . DRG 491 is not listed in Section 9789.22 (G)(2) for additional fees.
. Contractual A2reement Not Available for IBR. As such. 100% OMFS will be utilized to
calculate payment pursuant to §9789.2 1.
The table below describes the pertinent claim line information.
DETER11EWAHON OF ISSUE IN DISPUTE: Reimbursement of code 29846
Date of Service: 09:082014 -O909.2014
In Patient Hospital _______ ____________
. Workers’
Service Provider Plan Dispute Un.ft Comp N t
Code Billed Allowed Amount S Allowed o es
Amt.
DRG 491 $65,218.79 $1,42500 $14,803.38 1 $14,239.99 ONffS — Reimbursed
Amount = S12,8 14.99
Due Provider.

 

 

Created with Microsoft OneNote 2010
One place for all your notes and information

Simple Consultation (E&M)0 Paid Order 60 Days $805.32 no Lien Plus P&I

Wednesday, July 1, 2015

11:41 AM

 

 

Machine generated alternative text: DETERMINATION OF ISSUE IN DISPUTE: Reimbursement of codes 99205-25, 99354 &
96101-59 is recommended
Workers’ I
Comp ,
Notes
Allowed
DISPUTED SERVICE: Allow
__________ _________ _________ _________ _________ _________ _________ I reimbursement $237.67
DISPUTED SERVICE: Allow
reimbursement $114.35
DISPUTED SERVICE: Allow
reimbursement $453.30
Date of Service: 8.20.2014
Physician Services
Service
Code
Provider
Billed
99205
Plan Dispute
Allowed Amount
$275.00
$0.00
Units Multiple
Surgery
$275.00
1
96101-59
Amt.
N/A
99354
$125.00
$0.00
$125.00
1
N’A
$114.35
$500.00
$237.67
$0.00
$500.00
5
N’A
$453.30

 

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

99205

$275.00

$0.00

$275.00

1

 

$237.67

Award: $237.67

99354

$125.00

$0.00

$125.00

1

 

$114.35

Award: $114.35

96101

$500.00

$0.00

$500.00

5

 

$453.30

Award: 453.30

 

 

 

 

 

 

 

 

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted:

·ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes 99205-25, 99354 & 96101-59

 

Claims Administrator denied codes indicating on the Explanation of Review “We cannot review this service without necessary documentation. Please resubmit with indicated documentation as soon as possible”

 

Provider states on the IBR application “A copy of the report was attached to the SBR which we sent on January 20, 2015 and again, bill review has denied it with the same explanation as the original denial about needing documentation”

 

Provider’s report submitted titled “Psychological Consultation” states the injured worker was seen for an intake and assessment taking 1.0 hour with prolonged face to face taking an additional 45 minutes.

 

Psychological testing was administered under constant supervision. The total administration time took 3.0 hours, and the scoring and interpretation took 2.0 hours. ·

 

CPT 96101 -Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

 

. Provider documents all tests administered along with scoring and results in the report submitted.

 

A total of 5.0 hours for psychological testing.

·

Based on information reviewed, reimbursement is warranted for codes 99205-25, 99354 & 96101-59

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2015_301-600/CB15-0000343.pdf>

 

 

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One place for all your notes and information

ML104-95 Evaluation, 96101 and 96118

Saturday, July 4, 2015

3:14 PM

 

 

    ANALYSIS AND FINDING

     

    Based on review of the case file the following is noted:

     

    • ISSUE IN DISPUTE: Provider seeking remuneration for ML104-95 Evaluation, 96101 and 96118 Psychological Testing performed on Injured Worker 10/07/2014.
    • Claims Administrator reimbursed $0.00 of $6,331.45 with the following rational: “Claim denied and is currently in litigation.”
    • May 29, 2014 Letter from Claims Admin Legal parties, addressed to the Provider indicated the following: “Defendants do not believe that the applicant is entitled to a Psychiatric Panel at this time.”
    • August 12, 2014 Letter to Provider from Claimant’s Attorney requesting PQM Psychological Evaluation to include Causation and Apportionment.
    • Court Order, 07/17/2014, signed by Workers ’ Compensation Administrative Law Judge  "Granted "the following: “Applicant to go to PQME Eval w/ (Provider) to resolve psych issues.”
    • Provider is the PQME evaluator stated in the court order.
    • ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity facto

    Med Legal OMFS

    • ML104 criteria when compared to abstracted information provided on the Fee Disclosure and

    PQME Report revealed the following:

     

     

     

    1. Two or more hours of face-to-face time by the physician with the injured worker. Criteria Met
    1. Two or more hours of record review by the physician “8”hours Criteria Met
    1. Two or more hours of medical research by the physician. Criteria Not Met
    1. Four or more hours spent on any combination of two complexity factors (1)-(3), which shall count as two complexity factors.
    • Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity factor. Criteria Met
    1. Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors. Criteria Not Met
    1. Addressing the issue of medical causation upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the evaluation. Criteria Met, page  57 of PQME Report.
    1. Addressing the issue of Apportionment under the following circumstances: Criteria Met-Percentage of Apportionment Indicated, Page 61 –63 of PQME Report.
    1. Addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances: Criteria Not Met.
    1. A psychiatric or psychological evaluation which is the primary focus of the medical -legal evaluation. Criteria Met
    1. Addressing the issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section 4610. Criteria Not Met.

    ·

    • Criteria Met for ML104.
    • CMS 1500 reflects 96118 x 1 unit & 96118 x 1 unit = 56.68
    • 96118 Code Description: Neuropsychological testing (eg, halstead-reitan neuropsychological battery, wechsler memory scales and wisconsin card sorting test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
    • CMS 1500 reflects 96101 x 1 unit, 96101 x 1 unit and 96101 x 1 unit = $149.37
    • 96101 Code Description: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, mmpi, rorschach, wais), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.
    • Page 41 of PQME report indicates: 3.25 hours of “Psych Testing.”
    • QME abstracted information indicates 96118 x 1 unit
    • PQME abstracted information indicates 96101 x 2 units
    • Page 3 of PQM report indicates the following timing:
      • Face-to-Face with applicant (history and mental status exam): 4 hours
      • Record review and review of prior reports and significant commentary on medical records: 8 hours
      • Report Prep Time: 12 hours
      • Total time: 24 hours
    • 3 Hours are subtracted  from the overall time as 96118 x 1 unit and 96101 x 2 units are “per hour codes” and the value of the Physician’s time is included within the relative value of each code. Total Revised Time: 21 hours /84 Units

     

    Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2015_301-600/CB15-0000302.pdf>

 

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

ML104

$6,000.00

$0.00

$6,000.00

96

 

$5,250.00

 

96118

$56.00

$0.00

$21.33

2

 

$56.00

 

96101

$149.37

$0.00

$21.33

3

 

$149.37

 

 

 

Machine generated alternative text: Date of Service: 07ì26’2014
Med legal Services
$6000.00
Plan Dispute Assist
Allowed Amount Surgeon
$0.00 $6000.0 N/A
$0.00 $21.33
IVorkers’
Units Comp
Allowed
96 $5.250.00
Prodder
Bified
Service
Code
ML 104
96101
$149.37
96118
$56.00
$0.00
$21.33 N—A
2
$56.00
Med. Legal OMFS
Notes
Refer to Analysis
NA
3
$149.37
X2Units
Med. Legal OMFS

 

 

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Program Authorization UR Denials Overturned by IMR: Post
operative land physical therapy 2 x 8 for the lumbar spine:
Overturned

Psychological testing, 5 units: Overturned

Sunday, July 5, 2015

11:56 AM

Decision rationale: The Chronic Pain Medical Treatment Guidelines, 8 C.C.R. §§9792.20 -9792.26, page(s) pgs. 100-101. has the following to state about Psychological evaluations: Recommended. Psychological evaluations are generally accepted, well-established diagnostic procedures not only with selected use in pain problems, but also with more widespread use in chronic pain populations. Diagnostic evaluations should distinguish between conditions that are preexisting, aggravated by the current injury or work related. Psychosocial evaluations should determine if further psychosocial interventions are indicated. The interpretations of the evaluation should provide clinicians with a better understanding of the patient in their social environment, thus allowing for more effective rehabilitation. (Main-BMJ, 2002) (Colorado, 2002) (Gatchel, 1995) (Gatchel, 1999) (Gatchel, 2004) (Gatchel, 2005) For the evaluation and prediction of patients who have a high likelihood of developing chronic pain, a study of patients who were administered a standard battery psychological assessment test found that there is a Psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems. (Gatchel, 1999) Childhood abuse and other past traumatic events were also found to be predictors of chronic pain patients. (Goldberg, 1999) Another trial found that it appears to be feasible to identify patients with high levels of risk of chronic pain and

to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem. (Linton, 2002) Other studies and reviews support these theories. (Perez, 2001) (Pulliam, 2001) (Severeijns, 2001) (Sommer, 1998) In a large RCT the benefits of improved depression care (antidepressant medications and/or psychotherapy) extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status. (Lin-JAMA, 2003) See "Psychological Tests Commonly Used in the Assessment of Chronic Pain Patients" from the Colorado Division of Workers' Compensation, which describes and evaluates the following 26 tests: (1) BHI 2nd ed -Battery for Health Improvement, (2) MBHI -Millon Behavioral Health Inventory [has been superseded by the MBMD following, which should be administered instead], (3) MBMD -Millon Behavioral Medical Diagnostic, (4) PAB -Pain Assessment Battery, (5) MCMI-111 -Millon Clinical Multiaxial Inventory, (6) MMPI-2 -Minnesota Inventory, (7) PAI -Personality Assessment Inventory, (8) BBHI 2 -Brief Battery for Health Improvement, (9) MPI -Multidimensional Pain Inventory, (10) P-3 -Pain Patient Profile, (11) Pain Presentation Inventory, (12) PRIME-MD -Primary Care Evaluation for Mental Disorders, (13) PHQ -Patient Health Questionnaire, (14) SF 36, (15) SIP -Sickness Impact Profile, (16) BSI -Brief Symptom Inventory, (17) BSI 18 -Brief Symptom Inventory, (18) SCL-90 -Symp

 

Pasted from <http://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2013_1-10000/CM13-0006218.pdf>

 

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Program Authorization UR Denials Overturned by IMR: Post
operative land physical therapy 2 x 8 for the lumbar spine:
Overturned
PSYCHOLOGY
SURGERY
TESTING
PHYSICAL THERAPY
PHYSICAL THERAPY
MEDICATIONS
OTHERS
ACUPUNCTURE
CHIROPRACTIC
DME
Program Files Medical Necessity RFA: Right Elbow Cubital
Tunnel Release: Overturned
Program Files Medical Necessity RFA: Diagnostic Left L5
Medial Branch Facet Block QYT 1.00: Overturned
Program Authorization UR Denials Overturned by IMR:
PROSPECTIVE REQUEST FOR 1 QUALITATIVE 12 PANEL
URINE DRUG SCREEN :Overturned
Hospital Inpatient Billing and Payments
Medical Legal  Billing  and Payments
Evaluation and Management / Office Visits  
Billing  and Payments
Medical Legal  Billing  and Payments
Surgery Professional Component  Billing  and
Payments
Surgery Outpatient Services Hospital /Facility
Surgery Centers Billing  and Payments
Medication Billing  and Payments
Medical Legal  Billing  and Payments
Medical Testing   Billing  and Payments
Other  Billing and Payments
Program Files Billing and Payment Issues 20526-59-RT
Injection, therapeutic (eg, local anesthetic, corticosteroid),
carpal tunnel Performed on 11/25/2014
Hospital Emergence Room Department   Billing
and Payments
Program Files Billing and Payment Issues code 99283 and
reimbursement of codes 72100 and 71020
Program Files Billing and Payment Issues outpatient services.
Hospital is a Long Term Acute Care Hospital.
Program Files Billing and Payment Issues 63047 primary
procedure for laminectomy
Program Files Billing and Payment Issues 95832, 95831-RT,
95831-LT, 95851-RT, 95851-LT, and 95852 Range of Motion
and Muscle Testing services performed on 03/04/2014
DME   Billing  and Payments

PTP or Consult as Medical-Legal, Review of Records, Prolonged Services

Wednesday, July 15, 2015

7:30 AM

Providers, outside the AME or PQME, are missing the importance of performing a medical-legal.  

I recall when they adopted the RBRVS and did away with some outdated CPT codes. The one deleted code that most Providers were yelling foul over, was that of  review of medical records, which  supposedly,  were not separately payable any longer,  but bundled under Evaluation and Management, this is not entirely true.

Now, when one starts to read this post, they may believe I am foresting billing issues to get paid more, I am not, that is a secondary issue.

 

Outside the authorization for review of medical records by the adjuster, and the prolonged services face-to-face, for review of medical records, we have medical-legal reports,  in which review of medical records are paid.

 

As we go on, follow close to the logic, if there is sizable medical records to review and I as a Provider, wants to make sure I give the injured worker the best treatment possible, I am going to make sure I review those records, in detail.

Now, the norm is, that if  there are sizable medical records, that take hours beyond that allowed under prolonged services (fact-to-face, cannot keep the patient in the office for 8 hours) , of a E&M, chances  are that a medical dispute exists.  If a medical disputes exists, I will do a medical-legal, both for my patient and to ensure I have all the medical information available, as the law allows me to do this.

 

As the PTP, I can do a medical-legal, or based on the issues,  can refer to a  Chiropractic to do a medical-legal or I can refer to  a psych provider to do a medical-legal or to a surgeon ,(even if not a PQME or AME or even if an AME was already done)   As a PTP, why would I not want extensive medical evaluations such as medical-legals, if issues of treatment and other medical issues are disputed, it could be as simple, as denial of compound medications, to more complex, as to causation.

 

Like everything else in 2015, nothing is easy to understand and or apply, as it takes acute knowledge and understanding to do the above.  Most of all the law,  one has to have the law in hand, so if front of the WCAB, the law that says you can do what you are asserting is shown to the Judge, if it goes that far (Burden of Proof)

 

There are over 30 case laws on this  issue and numerous statutory laws, but just to show how and why it is done, we will take one case on the issue and put forth quotes as to the issues discussed above. 

 

This has been the law for many years, maybe for those seeing this as new, have a clearer understanding that some providers are missing laws that benefit them in treating injured workers, actually a lot of such laws.

 

The below case was decided in 2013,although dates of services were prior,  still good law under SB 863, however slight differences if the issue is medical necessity and an IMR was actually held, but we will not address that at this time, it still can and should be done, but other issues have to put forth first.

 

The case involves were a PTP requested a Chiropractic   to do a Permanent and Stationary report and the Judge  held it was a medical-legal evaluation, paid under the medical-legal fee schedule and not the OMFS.  In the decision, the appeals stated if it was a PQME the same results would have taken place.

 

If you are a Provider and this is new to you, do not do it without a complete understanding of several cases including an en banc published on the  issue and the statutory regulations addressing  this issue.

 

HOLLIE NELSON vs. CABRILLO UNIFIED SCHOOL DISTRICT;KEENAN ASSOCIATES REDWOOD CITY, November 14, 2014, Case No. ADJ2764972 (SJO 0267372) ORDER DENYING PETITION .for  RECONSIDERATION

 

"We agree with the WCJ that Dr. Newman's reports were prepared for the purpose of proving the extent of applicant's permanent disability and, therefore, they were medical-legal reports. (Lab. Code, §174620(a); see also Cal. Code Regs., tit. 8, § 9793(c)(2).) One of the main bases for determining the compensability of a medical-legal report is whether it was reasonable and necessary "with respect to the time when the expenses were actually incurred." (Lab. Code, § 4621 (a).) Here there is no question that, as the primary treating physician (PTP), Dr. Massey could properly request another physician to prepare a permanent and stationary report. (Lab. Code, § 4061.5; Cal. Code Regs., tit. 8, § 9785(c); cf. Lab.22Code., § 4663(c).) "

 

" As set forth in the Opinion on Decision, here we have Applicant requesting a comprehensive medical report from the primary treating physician Dr. Massey, and Dr. Massey making a designation to Dr. Newman.Defendant indicates that a medical-legal report is appropriate when completed by a Qualified Medical Examiner, an Agreed Medical Examiner, or a primary treating physician for the purpose of proving or disproving a contested claim and which meets the requirements of paragraphs (1) through (5) of 8 CCR Section 9793. I agree. Here, Dr. Newman was designated by the primary treating physician -and as indicated above an act contemplated by and acceptable pursuant to the California Labor Code "

 

"The definition of "contested claim" is varied, and can mean any of the following: a rejected claim; a presumptively compensable claim; a claim where temporary disability has not timely commenced or has not issued a timely notice of delay; a claim where liability is accepted but there are disputed medical facts. Here, Applicant's claim was accepted. Therewere disputed medical facts which existed on 11/30/2011, when Dr. Massey made the designation. In Lien Claimant's Exhibit 1, Dr. Newman's initial report at page 7 indicates:"She stated that Dr. Massey has wanted to provide to her water therapy and physical therapy "

 

"She stated that these treatment protocols have been denied." At page 11 Dr. Newman indicates:"05-18-11. Noted request for water therapy was denied. The UR denial was discussed." And later on the same page at the very bottom: "UR denial of aquatic therapy appeal dated 08-05-11. Maureen Mackey, M.D. Cited lack of evidence of functional deficits and frequency and duration of previous aquatic therapy." Clearly, there is evidence that there were disputed medical facts. Defendant's representation in the Petition for Reconsideration at page 7, lines27-28, and at page 8, lines 23-25, are a clear misrepresentation of the facts.As set forth herein, Applicant had a "contested claim" on 11/28/2011 when Dr. Massey made the designation to Dr. Newman. Further, Dr. Newman's reports were prepared by a physician as defined by the Labor Code, were at the request of a party, and were capable of proving or disproving a disputed medical fact, with the evaluation conducted and the reports prepared before the disputed medical facts were resolved, and the reports served timely pursuant to 8 CCR Section 9793(g) (1) through (5).As all of the requirements have been met, it is appropriate for Dr. Newman to bill for his evaluation and reports as a medical-legal expense, rather than services payable pursuant tithe OMFS.Defendant should be admonished for representing that there were no medical facts in dispute, when the evidence is clear that there were medical facts in dispute "

 

 "Whether Applicant was represented or not, upon the perfection of a medical dispute,Applicant was free to request a panel list from the Medical Unit. Applicant would have been free to select the specialty. Suffering from an orthopedic injury, and having undergone surgery, it would have been within the realm of reasonable for Applicant to have selected a chiropractic evaluator. This issue has been tried before the WCAB several times, and the AD has also addressed such disputes. There are published opinions that such a selection would be appropriate. The workers' compensation system has safeguards; if the selected panel doctor needs a referral to another specialist, then that can be obtained or arranged. If Applicant had the right to select a chiropractor for an evaluation, then it follows that Dr. Massey should also have had the right to designate a chiropractor for the preparation of comprehensive report.Here, if Dr. Newman was not qualified to comment as requested by Dr. Massey, Dr.Newman would have so indicated. Further, it is noted that Dr. Newman is on the list of qualified doctors for panel examinations. There is no dispute that Dr. Newman is properly qualified to render medical-legal opinions. Inserting a requirement that the primary treating physician explain and justify his or her designation is an unnecessary and undue burden for which there is no legal authority. "

 

The above is just one summary from one of many cases,  the purpose was not to show a  way for billing,  but to ensure and show under the laws that a Provider can justifiably spending as much time as required to ensure that proper treatment is provided. And if an E&M does not allocate that time and a dispute exists, the law allows a medical-legal even if not a PQME or AME, in which review of medical records are paid, among other tasks.

 

We could even take it a step further, suppose there are many medical records that cannot be reviewed under the face-to-face prolonged services, is it  now an authorization issue subject to the IMR process, as a review of medical necessity? We don't know, it has not been attempted yet, but if the facts and circumstances warrant, getting it authorized should not be an issue.

 

Not only are medical-legal evaluations essential, when a dispute exists but as a side issue, they are not subject to a lien filing , a lien fee nor subject to the time limits to file a, i.e. no lien required, done by petition.

A Provider who finds doing a medical-legal necessary based on the above summary, must also show how to bill and how collection procedures are completed for such services, including filing a "Petition for Non-IBR Medical Legal Dispute"if necessary.

 

Doing it properly  from the start, ensures few issues will arise, if not,  then its' purpose is defeated. As we have seen this issue for many years, when a case would deny a psych claim or injury and although the Psych Provider would  do a medical-legal evaluation , resulting with  some in collections having issue on how it get it paid, as a medical-legal, as not understanding the law.

 

The point is, that sometimes a Provider will see something as unfair and try borderline tactics to make it fair, when there are laws that address the  issue, making questionable tactics unnecessary.

 

So, when I read articles about a medical group  accused of providing unnecessary treatment, or Providers, in large numbers are treating on UR denials or a provider will not take new patients because they don't get paid for record review, I know these Providers are being given the wrong information on how the laws work, resulting in unnecessary and questionable acts.

 

Whatever the issue is today, trying to outsmart the system or find ways around the laws, is just plain unnecessary and foolish,  all one has to do, is be as smart as the system, that, is what some are missing.

 

In short, if it is reasonable and necessary for the treatment of an injured worker, a Provider gets paid for it, gets paid fee schedule, no sleight of hand necessary, no billing tricks necessary and no back room deals necessary, just know and find the law that addresses that issue. There are no "buts" in the above statement, it applies to all issues, it is time to leave such childish tactics to those who can afford the losses and are missing the treatment and services that should be afforded to an injured worker.

 

by: www.workcompliens.com 

 

http://www.workcompliens.com/4-Book-Medical-Legal-Disputes.html

 

 

Pasted from <https://www.linkedin.com/pulse/ptp-consult-medical-legal-review-records-prolonged-richard-boggan-jd?trk=mp-reader-card>

 

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2015 Book Lien Filing, Exceptions and
Time Limits
$225.00
2015 Book PPO Contracts How
They Apply SB 863
2015 PPO Contracts / Silent PPO All
States  Applications and Laws
2015 New Publication
Medical Legal Process – Disputes –QME –
AME- PTP – Interpreters – Copy Services
2015 New Publication
Pain Management / Psychiatric Treatment
2015 Book What Every Adjuster
Should Know About Liens
$225.00
2015 Book What Every Defense Attorney Should
Know  About Lien Disputes
$265.00
2015 Book MPN Issues, Denied Cases, Disputed
Liability,
Contested Liability and Burden of Proof
$235.00
$175.00
2015 Book Burn Centers
Collections Dispute Book
$275.00
2015 Hospitals Collections
Disputes
2015 Book Appearing at the
WCAB
$235.00
2015 Book Pleadings at WCAB
$375.00
2015 Book Implants,  DME,
Toxicology WCAB Disputes
2015 Book CIGA and Assigned
Claims  Purchased Work Comp
$375.00
2015 Book Lien Filing,
Exceptions and Time Limits
2015 PPO Contracts / Silent
PPO All States  Applications
and Laws
2015 Book What Every Defense
Attorney Should Know  About Lien
Disputes
2015 Book PPO Contracts
How They Apply SB 863
2015 Book What Every
Adjuster Should Know
About Liens
2015 Book MPN Issues, Denied
Cases, Disputed Liability,
Contested Liability and Burden of
Proof
2015 New Publication
Medical Legal Process – Disputes –
QME –AME- PTP – Interpreters –
Copy Services
2015 New Publication
Pain Management / Psychiatric
Treatment
2015 Book Burn Centers
Collections Dispute Book
2015 Hospitals Collections
Disputes
2015 Book Burn Centers
Collections Dispute Book
2015 Hospitals Collections
Disputes
2015 Book Appearing at
the WCAB
2015 Book Pleadings at
WCAB
2015 Book Implants,  
DME, Toxicology WCAB
Disputes
A Simple Program to ensure Reasonable
Reimbursement (Fee Schedule or Usual  and
Customary)1000 IBR Decisions Posted by billing code
and services -- Each Link opens full IBR decisions
regarding that billing code and billing services listed --
receive immediately via download / email
Over 1000 IBR Decisions Index

IBR Decisions 06252015

Wednesday, June 24, 2015

5:16 PM

 

72070 and 72110

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE:

 

Provider is dissatisfied with denial of codes 72070 and 72110·Claims administrator denied codes indicating on the Explanation of Review “The charge was denied as the report/documentation does not indicate that the procedure was performed.”· Provider documents in the report submitted that the worker was injured when a co-worker fell on top of her and she landed on her back and neck areas. Also noted in the report, medical necessity: lumbar spine 5 views –standard claim of pain LS area; thoracic spine 2 views claim of pain T spine area. Both with Findings ‘pending’. Diagnoses: contusion –back lower (922.31); contusion –back upper (922.33)·Based on information reviewed, Provider does document procedures were performed during the new patient exam and therefore, reimbursement of codes 72070 and 72110 is warranted

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1001-1200/CB14-0001066.pdf>

Machine generated alternative text: Date of Service: 03.08.2014
Physician Services
DISPUTED SERVICE: Allow
reimbursement $83.86
T -
Service Provider Plan Dispute
Code Billed Allowed Amount
Units
Multiple
Surgery
Workers’
Comp
Allowed
Amt.
Notes
72070
$57.23
$0.00 $57.23
1
NA
$57.23 DISPUTED SERVICE: Allow
reimbursement $57.23
72110
$83.86 $0.00 $83.86
1 j
NA
$83.86

 

97530-59 x 4 Units Physical Medicine services

 

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider seeking remuneration for 97530-59 x 4 Units Physical Medicine services performed on 02/26/2014 –03/05/2014.·The Claims Administrator denied the services indicating: “Per CCI Edits, the value of this procedure is included in the value of the mutually exclusive procedure.” ·NCCI edits reveal 97530 is Colum 2 Code when billed with Colum 1 Code, 97140.·Under certain circumstances, the paired codes in question may be unbundled with the use of modifier -59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.” ·Documentation of Patient visit includes Exercise Log noting duration of each exercise. ·Documentation regarding start and end times for 97530 Therapeutic Exercise and 97140 Manual Exercise, were not noted. Times entries for each exercise did not clarify whether the sessions were performed separately, simultaneously, or sequentially. The table below describes the pertinent claim line information

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1201-1500/CB14-0001349.pdf>

 

Machine generated alternative text: N:A N?A NA
Date of Service: 02262014— 0305/2014
Physical Medicine
Workers’
Service Provider Plan Dispute Assist Umts Comp Notes
Code Billed Allowed ‘ Amount Surgeon  Å.
97530-
59
S200.O0
$000
$200.00 N/A 4
SOEOO Refer to Analysis
97140
N.A
NA
NA Not In Dispute

 

WC004: Primary

Treating

Physician’s Permanent and Stationary Report (Form PR-4)

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider seeking additional remuneration for WC004 PR4 report up to 15 pages. Upon second bill review, no additional payment for WC004 was issued. ·Claims Administrator denied services with the following rational: Reimbursement has been calculated according to fee schedule guidelines.” ·WC004 PR-4 is reimbursed according to fee schedule at the rate of $38.68 for first page and $23.80 each additional page. Maximum of seven pages absent mutual agreement ($181.48).·Signed authorization reflects a pre-determined CPT agreement to PR4 PTP report up to 15 pages.·

Payment for 99499 x 12 units of Record Review service provided for Injured Worker on 06/10/2014 was issued on 08/20/2014 by the Claims AdministratorThe table below describes the pertinent claim line information.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1201-1500/CB14-0001425.pdf>

 

Machine generated alternative text: Date of Service: 06102014
Physician
Services
Workers’
Service
Code
Provider
Billed
Plan
Allowed
Dispute
Amount
Assist
Surgeon
.
L flits
Comp
N
otes
¡ 15
J pages
Amt.
WCOO4
S371.88
$18148
$19OE40
‘ NA
S371.88
$190.40DueProvider
Refer to An1ysis

 

CPT 97530-59

. Provider billed

codes 97140, G0283 and 97530-59

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider is dissatisfied with denial of CPT 97530-59. Provider billed codes 97140, G0283 and 97530-59. ·97530 is a time based code each 15 minutes.· Claims Administrator denied codes and indicated on the Explanation of Review “Per CCI edits, the value of this procedure is included in the value of the mutually exclusive procedure.” ·NCCI edits state that generally 97140 and 97530 are not reported together. However, Modifier Indicator column shows ‘1’ which states if the appropriate modifier is appended to the correct code, and proper documentation is supporting the code, then the NCCI edit may be overridden.

·

Pursuant to Labor Code section 5307.27, MTUS shall address, at a minimum, “the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.”

·On review of documentation submitted which included the testing that was done on date of service 05/02/2014. Provider documents time for CPT 97530 and 97140 with description of procedures performed. Therefore, reimbursement of 97530-59 is recommended.

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1201-1500/CB14-0001477.pdf>

 

Machine generated alternative text: Date of Senice: 05/0212014
Physician Seriices
WorkersTT
Service Provider Plan Dispute  Multiple Comp N
Code Billed Allowed Amount  Surgery Allowed ° 
97530-59 $1OOEOO $0.00 $100.00 2 N A DISPUTED SERVICE: Allow
reimbursement $70.38

 

CPT 97530-59 and 97750-59

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider is dissatisfied with denial of CPT 97530-59 and 97750-59. Provider billed codes 97140, G0283, 97530-59 and 97750-59.

·97530 and 97750 are both time based codes each 15 minutes. ·Claims Administrator denied codes and indicated on the Explanation of Review “Per CCI edits, the value of this procedure is included in the value of the comprehensive procedure.”·NCCI edits state that generally 97140, 97530 and 97750 are not reported together. However, Modifier Indicator column shows ‘1’ which states if the appropriate modifier is appended to the correct code, and proper documentation is supporting the code, then the NCCI edit may be overridden. ·Pursuant to Labor Code section 5307.27, MTUS shall address, at a minimum, “the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.” ·On review of documentation submitted which included the testing that was done on date of service 5/07/2014, no start and stop times are recorded as needed for code 97750. Provider documents time for CPT 97530 but not 97750. Therefore, reimbursement of 97750 is not

recommended

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1201-1500/CB14-0001478.pdf>

 

Machine generated alternative text: Date of Service: 5172014
Physician Services
Workers’ J
Provider Plan Dispute Multiple Comp \
Billed Allowed Amount S Surgery Allowed i o es
DISPUTED SERVICE: Allow
_____ ______ ________ _____ j reimbursement $70.38
97750 $6000 $OE00 560.00 1 NA $0C)0 DISPUTED SERVICE: No
reimbursement recommended

 

code 99499 x 3

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider is dissatisfied with denial of code 99499 x 3.·Claims Administrator denied code for three dates of service indicating on the Explanation of Review “Unlisted/BR svc not documented. Payment requires documentation explaining the service. See OMFS instructions for Procedures Without Unit Values.”· Documentation received included a Functional Restoration Program Authorization Request, Authorization and Reimbursement Agreement which states a request for additional 10 days/50 hours of OCPWC’s FRP (5 hours per day) at $1000 per day using CPT code 99499. ·Letter dated May 5, 2014 from Claims Administrator’s Utilization Review Department approved Outpatient Functional Restoration Program for 10 days (50 hrs) for low back. ·Provider submitted an FRP Team Conference Report documenting all the procedures performed with the injured worker for the three days for the Functional Restoration Program.· Based on the information reviewed, reimbursement for code 99499 x 3 is warranted. ·PPO contract was received and an 8% discount is to be applied.

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1201-1500/CB14-0001497.pdf>

 

Machine generated alternative text: Date of Service: 64/2014—66/2014
Functional Restoration Program
orkers’
Service Provider Plan Dispute Multiple Comp
Notes
Units
Code Billed Allowed Amount Surgery Allowed
I I I Anif.
99499 $3000.00 $0.00 $3000.00 3 NÌA
$2760.00 DISPUTED SERVICE: Allow
reimbursement $2760.00

 

codes 99205, WC007, 95886 and 95910

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider is dissatisfied with denial of code 99205. Provider billed codes 99205, WC007, 95886 and 95910. Claims Administrator reimbursed codes 95886 and 95910 and denied 99205. ·Claims Administrator denied code indicating on the Explanation of Review “Per report, no E/M was present that was separate and identifiable from the Nerve Conduction Study”

·

Documentation submitted included approved Neurology consult. ·Based on CPT guidelines for coding, modifier -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service: this modifier must be appended with an E/M service when services performed on the same day with other procedures done by the same physician. ·Based on information reviewed, Provider did not bill 99205 appropriately. Therefore, Claims Administrator was correct to deny code 99205 and no reimbursement is warranted

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001519.pdf>

 

Machine generated alternative text: Date of Service: 06/27/2014
Physician Services
Workers’
Service Provider Plan Dispute Multiple Comp
Notes
Units
Code Billed Allowed Amount Surgery Allowed
Amt.
99205 $38OE00 $0.00 $380X)0 1 N A
$0.00 DISPUTED SERVICE:
Reimbursement not
recommended.

 

WC004 Primary Physician

Permanent and Stationary Report

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider seeking remuneration for WC004 Primary Physician Permanent and Stationary Report provide to Claims Administrator for Injured Worker, Date of Service 05/12/2014.·Claims Administrator denied service with the following rational: “Required documentation is missing, please resubmit,” and “No additional reimbursement allowed after review of appeal/reconsideration.” ·Documentation reveals the Provider is the Primary Treating Physician. ·Although Injured Worker was returned to full duty without restrictions, Permanent and Stationary Status indicates “patient may require future medical care to the right knee with pain -relieving medications, injections, physical therapy, knee supports, and possibly surgery in the form of knee arthroscopy with partial menisectomy.” ·Report does not indicate that it is a non-reimbursable Return to Work Voucher indicated in §9789.14(a) ·Seven (7) page report is reimbursable under §9789.14(b)

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001533.pdf>

 

Machine generated alternative text: Date of Senice: 05/122014
Physician Seriices
Workers’
Senice Provider Plan Dispute Assist . Comp
Code Billed Allowed Amount Surgeon Allowed otes
WCOO4 S350.00 SO.0O $18148 N A 7 j S17948 Refer to Analysis

 

code 99215

 

 

ANALYSIS AND FINDING

Based on review of the case file the following is noted:· ISSUE IN DISPUTE: Provider is dissatisfied with denial of code 99215.·Claims Administrator denied code indicating on the Explanation of Review “Service/item included in the value of other services per CCI edits. Related service could be on separate bill.”· Provider billed codes 99215 along with 20605. Per NCCI edits, generally these two codes are not reported together. However, Modifier Indicator column shows ‘1’ which states if the appropriate modifier is appended to the correct CPT code, and documentation submitted supports the use of the code, then the edit may be overridden.· Provider billed 99215 with a modifier -25 which NCCI states is one of the appropriate modifiers to use. ·Based on review of the Primary Treating Physician Report (PR-2), the Evaluation and Management visit is supported along with the other code billed.·Provider billed a 99215 -Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; a comprehensive examination; Medical decision making of high complexity.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001537.pdf>

 

Machine generated alternative text: Date of Service: 05/29/2014
Physician Services
Workers’ I
Service Provider Plan Dispute Us Multiple Comp Notes
Code Billed Allowed Amount Surgery Allowed
Anit.
99215 to $16715 $OEOO $167.15 1 NA $12514 DISPUTED SERVICE: Allow
99214 reimbursement $125.14

 

Psychological Testing 96101

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider seeking full remuneration for Psychological Testing 96101 services performed on 04/08/2014. The Claims Administrator denied the service indicating: “No separate payment was made because the value of the service is included within the value of another service performed on the same day.” ·Based on the NCCI edits,96101 is a Colum 2 code paired with submitted procedure Colum 1 Code,99204. ·The paired procedure codes in question reflect modifier indicator “1,” allowing a bundled pair to be separately identifiable under certain circumstances. ·The documentation reflects a New Patient Consultation. ·EOR reflects Provider reimbursed for New Patient service 99204. ·99204 New Patient Consultation documentation states“3 hours” dedicated to 96101 “(psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., mmpi, rorschach, wais), per

hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report*).” ·Separately Identifiable service, 96101 Testing report and interpretation, can be found on page 4 through 7 of the Consultation Report. CMS 1500 reflects Modifier -59 Significantly Separate and Identifiable Service, affixed to the appropriate Colum 2 code.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001539.pdf>

 

 

 

Machine generated alternative text: Date of Service: 04/08t2014
Physician Services
Workers’
Service Provider Pian Dispute Assist Multiple Comp N
Code Billed Allowed Amount Surgeon Surgery Allowed o es
Amt.
96101 $27198 $000 $27L98 N A N A S24478 PPO Contract
99204 1 SNA $NA SNA NA NA NA Servicenotindispute

 

code 99202.

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE  :Provider is dissatisfied with reimbursement of code 99202.·Claims Administrator changed billed code 99202 to 99212 indicating on the Explanation of Review “Allowance based on F/U visit”·Provider billed code 99202 and states “The bill accurately represents the level of service provided. Altering & down-coding our service is without merit. See report attached.” ·On review of narrative report submitted by Provider, documentation states “Injured worker is being seen at the request of the treating physician and has been authorized by the claims adjuster for employer. The patient is being evaluated with respect to the alleged work related injury to the right hip while working on June 10, 2014...”·99212 -Office or other outpatient visit for the evaluation and management of an established patient ·99202 -Office or other outpatient visit for the evaluation and management of a new patient·No evidence submitted that patient has been seen by this Provider and was a follow-up visit. Provider states the bill submitted accurately represents the level of service as a new patient exam.

·Based on information reviewed, additional reimbursement of code 99202 is warranted

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001541.pdf>

 

Machine generated alternative text: Date of Senice: 06/1912014
Physician Serices
Workers’
Service Provider Plan Dispute Units Multiple Comp Sotes
Code Billed Allowed Amount Surgery I 4llowed
N . $8635 DISPUTED SERVICE: Allow
99202 $16OE00 $5132 $10&68 1 ¡
reimbursement $35.63

 

0101T -R

Extracorporeal

shock wave

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider seeking remuneration for 0101T-R Extracorporeal shock wave involving musculoskeletal system, not otherwise specified high energy, performed on 05/20/2014.·Claims Administrator denied services with the following rational: “Shock wave of the shoulder is not approved by FDA. This product/procedure is only covered when used according to FDA recommendations.”· Available for review are Procedure notes for the following dates of service: 05/20/2014, 05/21/2014 & 05/22/2014. CMS 1500 CPT 0101T date of service 05/20/2014.·Documentation for 05/20/2014 does not clearly indicate ESW performed. Documentation Terminology appears similar to non ESW procedure day 05/21/2014 & 05/22/2014.·Unable to recommend reimbursement due to insufficient documentation

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001542.pdf>

 

Machine generated alternative text: DETERMINATION OF ISSUE IN DISPUTE: O1O1T-R
Date of Service: 05/20.2014
Physician Services
Workers’
Service Provider Plan Dispute Units Comp Notes
Code Billed Allowed Amount Surgeon  ____________
O1O1T-R $1,450M0 $0.00 S1,45OE00 N A 1 $0.00 Refer to Analysis

 

code 29827

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted: ·ISSUE IN DISPUTE: Provider is dissatisfied with reimbursement of code 29827. Claims Administrator reimbursed $1787.60, physician fee schedule allowance, indicating on the Explanation of Review “The charge exceeds the Official Medical Fee Schedule allowance. The charge has been adjusted to the scheduled allowance.”·Based on review of the operative report, Provider performed a rotator cuff repair.  Provider billed code 29827,Arthroscopy, shoulder, surgical; with rotator cuff repair, on a UB-04 CMS 1450 form for an ambulatory surgery center. ·Provider was reimbursed per the Physicians Fee Schedule and not the OPPS fee schedule: 29827 -Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. ·Based on information reviewed, additional reimbursement of code 29827 is warranted.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001503.pdf>

 

Machine generated alternative text: Date of Service: 612/2014
Ambulatory Surgery Services
Workers’
Service Provider Plan Dispute Multiple Comp Notes
Code Bified Allowed Amount Surgery Allowed
___ I j _Amt._ __
29827 $15,138.56 T$l,787.60 S2,533.59TNA S4.29&25 DISPUTED SERVICE: Allow
I  reimbursement $2,510.65

 

code 64555

 

ANALYSIS AND FINDINGBased on review of the case file the following is noted: ·ISSUE IN DISPUTE

:Provider is dissatisfied with reimbursement of code 64555.·Claims Administrator reimbursed $108.64 indicating on the Explanation of Review “Value of surgery code reduced according to a visit billed within the follow-up days which previously reviewed.”·Each date of service is billed separately per procedure and processed as such. Claims Administrator was incorrect to reduce code 64555 based on another procedure billed at a later date. ·Based on information reviewed, additional reimbursement of code 64555 is warranted.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001506.pdf>

 

Machine generated alternative text: Date of Service: 02/18,2014
Physician Services
Workers’ I
Service Provider Plan Dispute Us Multiple Comp Notes
Code Billed Allowed Amount Surgery Allowed
Amt.
$12514 $21501 DISPUTED SERVICE: Allow
additional reimbursement
$106.37

 

63688,63661

and 63661-59

Surgical Services

 

 

ANALYSIS AND FINDING  Based on review of the case file the following is noted:·ISSUE IN DISPUTE :Provider seeking $2,750.12 in remuneration for 63688,63661 and 63661- 59 Surgical Services performed on Injured Worker 02/17/2014. · Claims Administrator denied services stating, “No Payment was made because the value of the service is included in the value of another services performed on the same day.” · CMS 1500 form indicates Place of Service as Ambulatory Service. ·Operative note reflects Ambulatory Services performed in Ambulatory Service setting reflected on CMS 1500. ·CMS 1500 and Operative note reflect only the procedures in question, 63688 as the primary procedure.

·CPT Codes entered into the NCCI data base; not edits were recognized for Ambulatory Service Setting. ·2014 Reimbursement Formula as follows: APC relative weight x adjusted conversion factor (Ventura County)x 0. 82 Workers’ Compensation Multiplier, pursuant to Section 9789.30(aa)·$2,750.12 reimbursement is warranted.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1501-1800/CB14-0001510.pdf>

 

Machine generated alternative text: Date of Service: 02/17/2014
Ambulatory Surgery Services
Service Code
Provider Plan Dispute Workers’ Comp
Units Notes
Billed Allowed Amount Allowed Amt.
63688
$5,000.00 S0O0 $1,980.12 1 S1,98OE12 Refer to Analysis
63611
$3,000.00 $0C)0 $385.00 I 1 $385.00 Refer to Analysis
$3,000.00 $000 $385.00 1 $38500 Refer to Analysis
63611-59

 

 

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How Did These Requests for Authorization Get So Bad, Almost Ridiculous

Tuesday, June 16, 2015

7:02 AM

With over 300,000  IMRs (Independent Medical Review Decisions), showing what was requested, with  the documents submitted and the treatment guidelines used to apply to the decisions in  great detail , it is not hard to see patterns and constancy by providers.

 

My latest compilation of data is the decisions (IMRs) regarding,  "Retrospective Reviews": Now, one may think that an application for a retrospective utilization review would have benefits, such as hindsight  showing how the patient actually benefited from the treatment already provided, seems simple.

 

Note: These IMR decisions are based on an insurance companies UR (utilization review) denials, therefore those getting their treatment authorized should not be included in the conclusion of the data compiled, unless insurance companies are being overly liberal, which may be the case in some instances. .

 

The data reveals  an unbelievable sloppiness in most of these RFAs which end up in the IMR process, which shows that it cannot be the Providers requesting these RFAs, as they would not submit such documents that lack medical professional responsibility,  that was the determination of whether a patient  would get necessary  treatment or not. ( the statement encompass both prospective review requests and retrospective review requests)

 

How can one request a retrospective review of medications and not put what dosage that was being given (hundreds of these).

 

How could one request a retrospective review of 12 Chiropractic visits and nowhere in those 12 visits is it documented that the patient is benefiting from those visits.

 

How can one not understand the procedure for defective URs and IMRs, when IMRs actually state they did not receive all the medical reports, an appeal is mandated.

 

There are tens of thousands of like examples, so many  that one has to conclude in the majority of the time it is not the fault of the IMR system why injured   workers may be going without treatment or providers without payments when treating on a UR denial.

 

Understandable, prior to 2012 everything was more or less a game of chance, no consistency  and little law applied as almost everything was settled, we have to let it go, it no longer exists and has not, coming on 3 years now. 

Providers have to read these RFAs for authorization and the IMR decisions  and see what is going out in their name, as they may shocked as to the lack of simple medical information and lack of documentation or incorrect requests. Or Providers have to at least train and give those who are submitting these RFAs on their behalf  for authorization, proper training and guidelines, as they are good people, but the complications of the guidelines  in 2015, requires a precise system that they have to operate under.

 

What these IMRs reflect in upholding UR denials, is not a great reflection on Providers, as to detail and documenting medical information, not even close.

 

 Getting treatment authorized in accordance with what the IMRs are requesting is beyond simple, because they are consistent, so no guess work in what you have to submit or show and even if treatment outside the guidelines they allow -- "..Clinical documentation submitted for review failed to provide documentation of exceptional factors to warrant nonadherence to guideline recommendations,.."

 

In fact,  if the IMR system is being challenged, as to application and effectiveness, all those parties defending the IMR system , just need to show some ( the majority ) of these IMRs decisions, to show its necessary function . With such a showing, (IMR  Decisions)  the only finding that could possible follow,  will be that the system is more than necessary, even  essential to ensure the kind of sloppiness reflected in these decisions is  not spread throughout the treatment for injured workers  .

 

by: www.workcompliens.com

 

below is one of the better ones:

 

 Retrospective request for Oxycontin 20mg #60 for 11/09/13:Upheld

 The lowest possible dose should be prescribed to improve pain and function. Continuing review of the overall situation with regard to nonopioid means of pain control. Ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Consider the use of a urine drug screen to assess for the use or the presence of illegal drugs.

 

"The records provided do not provide a documentation of response in regards to pain control and functional improvement to opioid analgesic for this patient. The continued review of overall situation with regard to nonopioid means of pain control is not documented in the records provided. As recommended by MTUS a documentation of pain relief, functional status, appropriate medication use, and side effects should be maintained for ongoing management of opioid analgesic, these are not specified in the records provided. MTUS guidelines also recommend urine drug screen to assess for the use or the presence of illegal drugs in patients using opioids for long term. A recent urine drug screen report is not specified in the records provided. Whether improvement in pain translated into objective functional improvement including ability to work is not specified in the records provided With this, it is deemed that, this patient does not meet criteria for ongoing continued use of opioids analgesic. The medical necessity of Oxycontin 20mg #60 for 11/09/13 is not established for this patient

 

 

 

Pasted from <https://www.linkedin.com/pulse/how-did-requests-authorization-get-so-bad-almost-richard-boggan-jd?trk=mp-reader-card>

 

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WC: Collection Processes, Changed From Reactive Responses to Solutions

Tuesday, June 16, 2015

7:26 AM

In 2015, there are still several types of collection methods, with each holding varying degrees of production.

 

First, we have the phone collections and lien filing alone, collections procedure, which I like to call the “ Novice provider type”, of collections.

 

I call this the  Novice provider type of collections because they have yet to utilize the IBR process or IMR process ( yes the collection process involves the IMR process, i.e., when to appeal an IMR when missing medicals—happens often-few appeal even when IMR states they did not have all the medicals) )to bring forth viable solutions to disputes.

 

In this process, we blame the provider for low settlements and a buildup of valueless receivables.

Now, the  Novice provider collections’ method, is where a provider is still working by the old rules,  of treating on UR denials and basically attributes the slowing of receivables to a clog up in the system, which they hope will eventually unclog and all those millions of outstanding will reap benefits.

 

Sometimes, these providers feel or are told that they were doing something on the thin line of being prohibited (illegal referrals, purchasing accounts which is not prohibited etc.) and are therefore accepting low settlements. However in actuality, this is not the case, but they do not want to yell foul too often, which is incorrect, one thing one cannot do is outsmart the system , one can only be as smart as).

 

For these types of collections, a collector is put in an impossible job, as the search for template responses to get adjusters to pay   has a very limited production in 2015

 

Then we have the middle collections, sometimes called the confused collections process, meaning they know the new laws and procedures that must be applied, however their application in applying these laws are more responsive in nature, rather than assertive, as to the laws under SB 863  as an assertive and proactive approach as was and is   intended.

 

In addition, their learning process  all comes from responsive methods instead of assertive application in finding solutions and applying the correct laws. They have tried the IBRs and application of the IMRs laws, only to find limited solutions, so they revert back to liens, as methods of settlements, which is not bad, but incomplete.

 

Now, the first two processes, still leave providers in a state of confusion, as they receive instability from those asserting the same as to what the laws are, and are communicating them incorrectly to their providers, so these providers just keep doing things as they always have, hoping for better days.

 

Then we have the masters, those who find solutions under SB 863 and the laws that followed, as SB 863 gave providers solutions to objections, underpayments and denial of treatment requests These providers get favorable IBR decisions, these providers have mastered the IMR process and get UR denials overturned, and who warrant and demand and respect at the WCAB, beyond nuisance settlements.

The biggest concern Providers should have presently, is outstanding receivables, regardless of the lax settlements that may be coming in -- 2016 will not reflect that, so millions may disappear if urgency in 2015 is not practiced.

 

It spins the mind, that a $10,000.00 file can turn into zero and or $1,000.00, just based on a simple law, procedure or the knowledge base of the one perceiving it, which is very common and applies to the majority of collection dispute files. With so many laws and or procedures that may attach to a dispute file, being wrong is costly. Not knowing you are wrong, is more costly, and that is more common place than the former.

 

The master collection procedures, understands the expedited nature of dispute files and are ahead of the fast moving train that can  make viable collections dispute files from fee schedule to 10 cents on the dollar within days.

 

They are the ones that I write about, as I read their IBR decisions, as I read their IMR decisions, with all the medical information to get a UR denial overturned, these are the ones that create law when law needs to be created, that favor providers. These are the providers who know 2015 is about solutions and not seeking magic words to get adjusters and defense attorney to resolve below what the law states is mandated.

 

What the DWC did, when the published IBR decisions , when the publish IMR decisions and when they published WCAB decisions , was and is to show that some are benefiting more under SB 863 then any time prior, and it also shows  that some providers are still at a loss under SB 863, resulting in unnecessary losses and closure of dispute files, as SB 863 was intended to bring about. But most importantly, they have shown us that there is a solution to every underpayment and every objection and every possible method of doing it correctly,  as so a provider does not  to sustain unreasonable losses.

 

Below are just a few objections, that have been overcome by those who understand the system in 2015:

 

Provider seeking remuneration for the following Ambulatory Services performed on 11/03/2014: 64635-SG $860.00; 64635 -SG-50 $430.00;64636-SG $568.00; & 64636-SG-50 $568.00. •Claims Administrator denial rational: “Reimbursement for this service is not payable to Ambulatory Surgical Centers  --- Incorrect

 

. Claims administrator reimbursed $59.12 indicating on the Explanation of Review “The number of units billed for this procedure code exceeds the reasonable number usually provided in a given setting as defined within the Medically Unlikely Edits (MUEs) which is published and maintained by the Centers for Medicare and Medicaid Services” This denial is incorrect as these are lab charges not physician charges.

 

Claims Administrator reimbursed $113.34 of billed amount $1396.80 indicating on the Explanation of Review “Charge for pharmaceuticals exceed the fees established by the fee schedule/UCR rates” Compound Medication Claim Administrator Incorrect

 

Claims Administrator denied service with the following rational: “The visit or service billed occurred within the global surgical period and is not separately reimbursable.”     If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57

 

Claims administrator down coded ML 104 to ML 102 indicating on the Explanation of Review “Documentation doesn’t support the level of services” and “Lower ML 104 to ML 102.

Provider seeking full remuneration for 99214 Evaluation and Management Services performed on 10/27/2014.•Claims Administrator applied reimbursement relating to CPT 99213 with the following rational: “The documentation doesn’t support the level of service billed. Reimbursement was made for a code that is supported by the description and documentation submitted with the billing

 

95913 nerve conduction studies; 13 or more studies, performed on 9/26/2014. •Claims Administrator denied the service with the following rational: “The documentation does not support the level of service billed. Reimbursement was made for a code that is supported by the Documentation  submitted with the billing .” Reimbursed as 95912 Nerve conduction studies; 11-12 studies

 

Med-Legal ML104 services performed on 12/05/2014.•Claims Administrator reimbursed the Provider $8,813.54 of $11,313.54 with the following rational: “89 Units Workers Compensation Fee Schedule Adjustment.” •CMS 1500 Form indicates the Provider billed 180 Units

:ML104-95 Evaluation, 96101 and 96118 Psychological Testing performed on Injured Worker 10/07/2014. •Claims Administrator reimbursed $0.00 of $6,331.45 with the following rational: “Claim denied and is currently in litigation.

 

Reimbursement of code 95913.•Claims Administrator reimbursed $179.49 indicating on the Explanation of Review “The Official medical Fee Schedule does not list this code. An allowance has been made for a comparable service”• CPT 95913, Nerve conduction studies; 13 or more studies,is listed on the Medical Fee Schedule. •Provider submitted an EMG/NCV and Neurodiagnostic Testing and Consultation Report of Bilateral Lower Extremities where he documented 13 different nerve conduction studies performed on date of service 9/17/2014

 

:ISSUE IN DISPUTE: Provider disputing reimbursement for ML104, 73110, 72110, 73562, 73030 and 72040 services performed on 03/27/2014. •Claims Administrator ML104 reimbursement rational: “FCE Not Requested,” and “Not Authorized.” •FCE “Functional Capacity

 

Psychotropic therapy, once per week for one week: Overturned

 

TWELVE (12) PHYSIOTHERAPY VISITS :Overturned

 

MRI Arthrogram Right Ankle:Overturned

 

MRI of right knee: Overturned

 

Pain management consultation:

Overturned

 

Follow-up internal medicine evaluation: Overturned

 

Clonidine 0.1mg #90: Overturned

 

Initial Ortho Consult for Left Elbow and Left Wrist: Overturned

 

Med panel to evaluate hepatic and renal function: Overturned

 

Retrospective request for Norco 10/325 mg #60 DOS:1/24/14:

Overturned

 

Pain Management Consultation:

Overturned

 

Psychological Evaluation:

Overturned

 

Right Shoulder Arthroscopic Rotator Cuff Repair with Decompression:

Overturned

 

POST-OP PHYSICAL THERAPY FOR THE RIGHT SHOULDER 3 X 4

:Overturned

 

Neurosurgical consult: Overturned

 

Referral to regarding further therapy:

Overturned

 

Prilosec 20mg #30: Overturned

 

EMG of the bilateral upper extremity

: Overturned

 

CELEBREX 200MG #30:

Overturned

 

Left Knee Video Arthroscopy, Medial Meniscectomy : Overturned

 

Right Latissimus Transfer with one to two day Inpatient Length of Stay

:Overturned

 

by: www.workcompliens.com

There are thousands of decisions showing solutions being published everyday, basically all one has to do is mirror what was done by those who  have mastered SB 863 and all the supporting laws, and if an issue exists without a solution  published, then use  prior decisions  as a guide on how to get solutions.

 

One does not look to someone who  succeeds 1 out of 10 times, but looks to someone who succeeds 9 out of 10 times and finds out how they are doing it.

 

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WC: How Soon Should Multidisciplinary Pain Programs be Offered to IWs

Tuesday, June 16, 2015

7:33 AM

The IMR (Independent Medical Reviewers) have expanded the knowledge base and orders for treatment for injured workers, that were not readily available prior to the IMR process.  Even though these programs existed for years, getting such long term programs authorized  were not easy ,nor was receiving  reasonable payments for the same services (of which the IBR process has issued numerous decisions for the provider based on these services). The IMR process and the IBR process has changed that, making Multidisciplinary Pain Programs more available  to injured workers and more financially  feasible for providers to perform. In fact the IMR process and IBR process has given an accessibility  of treatment and services that were limited prior to 2013, both in authorization and reasonable payments, this is also where providers who persist in treating on UR denials are being deprived of those benefits put forth in these IMR decisions.

 

“The likelihood of return to work diminishes significantly after approximately 3 months of sick leave. It is now being suggested that there is a place for interdisciplinary programs at a stage in treatment prior to the development of permanent disability, and this may be at a period of no later than 3 to 6 months after a disabling injury. (Robinson, 2004) (Gatchel, 2003) This early intervention has been referred to as “secondary treatment,” and differs from the more traditional, palliative care pain programs by not only the earlier onset of treatment, but by treatment intensity and level of medical supervision. (MTUS) Chronic Pain Medical Treatment Guidelines (Page 30-32)

 

Functional Restoration Program. The MTUS guidelines page 49 recommends functional restoration programs and indicate it may be considered medically necessary when all criteria are met including (1) adequate and thorough evaluation has been made (2) Previous methods of treating chronic pain have been unsuccessful (3) significant loss of ability to function independently resulting from the chronic pain; (4) not a candidate for surgery or other treatments would clearly be (5) The patient exhibits motivation to change (6) Negative predictors of success above have been addressed.

 

 California Medical Treatment Utilization Schedule recommends that a Functional Restoration Program is appropriate for patients who have not responded to previous chronic pain treatments and are unlikely to show any significant clinical improvement from further treatment.

 

California Medical Treatment Utilization Schedule recommends a functional restoration program for patients that have had an adequate and thorough baseline evaluation to support functional improvement throughout the program and documentation of willingness and a motivation to change

 

CA MTUS Guidelines, functional restoration programs may be recommended for patients with conditions that put them at risk of delayed recovery, when documentation indicates that the patient is motivated to improve and return to work and the criteria listed by the guidelines is met. It further states that an adequate and thorough evaluation should be made including baseline functional testing so follow-up with the same test can note functional improvement, prior to admission to a functional restoration program

 

 Common Errors in RFA

 

  • Fails to provide any evidence that the patient has undergone a comprehensive psychological or physical evaluation to determine the patient's appropriateness for a Functional Restoration Program.
  • Documentation submitted for review does not provide evidence that the patient has exhausted all lesser forms of conservative treatment and will not significantly improve as a result of further conservative treatments.
  • Does not clearly identify a duration of treatment.
  • The appropriateness of that treatment cannot be established
  • The clinical documentation as it is submitted does not contain any evidence of thepatient's motivation to change or a functional baseline assessment to assist in determining functional improvements related to the program.
  • The clinical documentation submitted for review does not provide evidence that treatment beyond the recommended 20 sessions is necessary
  • It is not clear whether the patient is a candidate for surgery or other treatment, whether he had exhibited motivation to change, and whether negative predictors of success have been addressed.
  • Request for six weeks of treatment in a functional restoration program is not supported as the patient does not meet all of the criteria and the request for treatment for 6 weeks exceeds the guideline recommendations
  • Negative predictors of success have not been addressed
  • There are no exceptional factors noted within the documentation to support extending treatment beyond guideline recommendations.

 

The below is taken from (MTUS) Chronic Pain Medical Treatment Guidelines (Page 30-32) discusses functional restoration programs. Also called Multidisciplinary pain programs or Interdisciplinary rehabilitation programs, these pain rehabilitation programs combine multiple treatments, and at the least, include psychological care along with physical therapy & occupational therapy

(including an active exercise component as opposed to passive modalities)

 

Chronic pain programs (functional restoration programs) Recommended where there is access to programs with proven successful outcomes, for patients with conditions that put them at risk of delayed recovery. Patients should also be motivated to improve and return to work, and meet the patient selection criteria outlined below. Also called Multidisciplinary pain programs or Interdisciplinary rehabilitation programs, these pain rehabilitation programs combine multiple treatments, and at the least, include psychological care along with physical therapy & occupational therapy (including an active exercise component as opposed to passive modalities). While recommended, the research remains ongoing as to (1) what is considered the “gold-standard” content for treatment; (2) the group of patients that benefit most from this treatment; (3) the ideal timing of when to initiate treatment; (4) the intensity necessary for effective treatment; and (5) cost-effectiveness. It has been suggested that interdisciplinary/multidisciplinary care models for treatment of chronic pain may be the most effective way to treat this condition. (Flor, 1992) (Gallagher, 1999) (Guzman, 2001) (Gross, 2005) (Sullivan, 2005) (Dysvik, 2005) (Airaksinen, 2006) (Schonstein, 2003) (Sanders, 2005) (Patrick, 2004) (Buchner, 2006) Unfortunately, being a claimant may be a predictor of poor long-term outcomes. (Robinson, 2004) These treatment modalities are based on the biopsychosocial model, one that views pain and disability in terms of the interaction between physiological, psychological and social factors. (Gatchel, 2005)

 

There appears to be little scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation compared with other rehabilitation facilities for neck and shoulder pain, as opposed to low back pain and generalized pain syndromes. (Karjalainen, 2003) Types of programs:There is no one universal definition of what comprises interdisciplinary/multidisciplinary treatment. The most commonly referenced programs have been defined in the following general ways (Stanos, 2006): (1) Multidisciplinary programs: Involves one or two specialists directing the services of a number of team members, with these specialists often having independent goals. These programs can be further subdivided intofour levels of pain programs: (a) Multidisciplinary pain centers (generally associated with academic centers and include research as part of their focus) (b) Multidisciplinary pain clinics (c) Pain clinics (d) Modality-oriented clinics (2) Interdisciplinary pain programs: Involves a team approach that is outcome focused and coordinated and offers goal-oriented interdisciplinary services. Communication on a minimum of a weekly basis is emphasized. The most intensive of these programs is referred to as a Functional Restoration Program, with a major emphasis on maximizing function versus minimizing pain. See Functional restoration programs.

 

Types of treatment: Components suggested for interdisciplinary care include the following services delivered in an integrated fashion:

(a) physical treatment;

(b) medical care and

supervision;

(c) psychological and behavioral

care;

(d) psychosocial care;

(e) vocational

rehabilitation and training; and

(f) education.

see more for complete understanding

 

see more: www.workcompliens.com

There are hundreds of IBR decisions for the services that are  the subject of this Article.

 

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From Program 2015 Papers Articles:WC:Collection Paper vs. Providers'
Receivables 10 Cents on The Dollar?
From Program 2015 Papers Articles: We Fooled Providers for So Long,
They Now Turn a Deaf Ear to Us--Help.
From Program 2015 Papers Articles: WC: Providers Have Always Been
Underpaid, Just No One Ever Told Them
From Program 2015 Papers Articles: WC: Receivables= Strategic,
Tactical,  Operational & Contingency Planning
From Program 2015 Papers Articles: WC: Reading Laws Incorrectly,
Putting Receivables on a Path of Default
From Program 2015 Papers Articles: Chiropractic Beyond 24 w/o Surgery
/ When Necessary for Wrist and Hand
From Program 2015 Papers Articles: WC: Why Some Providers are
Cheating Themselves out of Payments Due
From Program 2015 Papers Articles: WC: The Power Of Requests for 2nd
Bill Review and Notice to File Lien
From Program 2015 Papers Articles: UR Certification, Same as Authorized,
PBM, MPN, PPO Denied Body Part?
From Program 2015 Papers Articles: The Day of a Work Comp Collector,
That What We Perceive No Longer True
From Program 2015 Papers Articles: Mythical Search For The Answer to
94% Authorized Treatment/ Services
From Program 2015 Papers Articles: WC: Treatment / Collection Disputes
The One Thing That Can No Longer be Glossed Over
From Program 2015 Papers Articles: WC: Understanding MTUS, ODG, ACOEM
and Non-MTUS Treatment Guidelines.
From Program 2015 Papers Articles: DWC States No More Above Fee Schedule
for...
From Program 2015 Papers Articles: Toxicology: Drug Screen Why Not Paying
as...
From Program 2015 Papers Articles:
Adjusters-Liens, Who are They, What Did They
Do with The Old Adjusters
From Program 2015 Papers Articles :WC: Frauds
That Survived SB 863, PPOs, MPNs, Prescription
Drug Cards
From Program 2015 Papers Articles: (PBM),
DISCOUNTED PAYMENTS FOR
PHARMACY, BIGGEST FRAUD SINCE PPOS
OR ?
From Program 2015 Papers Articles:
determination of Medical-Legal Dispute, Interpreter,
Copy Service,
From Program 2015 Papers Articles: WC: Bill
Reviews / 2nd Reviews--- Insurance Companies
Not Playing Nice
From Program 2015 Papers Articles:WC: The
Myth About Liens, Inside Looking Out.
From Program 2015 Papers Articles:WC Sanctions
Some May Not Understand It, But

WC: 10 Common Mistakes In Billing and Collections That Providers Make

Thursday, June 18, 2015

8:12 AM

63650 Most of the time disputed as underpaid or not paid at all:

63650-59 can be coded for each site that the electrode catheters are placed. According to the CMS, Medically Unlikely Edit (MUE) file code 63650 can be coded twice for one date of service.· Code 63650 has a status indicator of “S” indicating that a multiple procedure reduction is not applicable.· code 63650-59

Note: surgeons and outpatient services are mostly incorrectly paid or  underpaid-no payments when payments warranted

97530 and 97140:

NCCI edits reveal 97530 is Colum 2 Code when billed with Colum 1 Code, 97140. ·Under certain circumstances, the paired codes in question may be unbundled with the use of modifier -59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter

Psychological testing with Evaluation and  Management use modifier 59

Evaluation and Management Service 99215.·Based on the NCCI edits, a code pair exist between CPT 99215 and 96101.·Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation supports the use of the procedure code, then the edit may be overridden

. Per CCI edits, generally codes 99205 and 96101 are not billed together. However, Modifier Indicator column shows ‘1’which states if an appropriate modifier is attached to the correct CPT code and documentation supports the use of the code then the CCI edit may be overridden. Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI edit include:-Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RIGlobal surgery modifiers: 24, 25, 57, 58, 78, 79-Other modifiers: 27, 59, 91

Example: Provider billed codes 96101 and 96116 along with 99205.99205 was reimbursed by Claims Administrator. Generally 96101 and 96116 are not billed with 99205, however, Modifier Indicator column shows ‘1’ which states if the correct code is appended with a qualifying modifier, and documentation is submitted to support the code billed, then the edit may be overridden. Provider did not append an appropriate modifier for codes 96101 and 96116.

Note: Psych  services should be a provider that has little trouble getting paid as the laws and treatment guidelines reinforce treatment for psych in relation to treating all injuries - guidelines very liberal for psych intervention

45-day rule in California Code of Regulations, Title 8, section 9785(f)(8)

DWC states, “The purpose of the 45-day rule in California Code of Regulations, Title 8, section 9785(f)(8) is to make sure that in the case of continuing treatment, that the patient’s progress is monitored no less than once every 45 days.” However, “Within a 45-day period, the primary treating physician can bill for as many PR-2’s as are medically necessary.”

·

Example: The Provider is the “Primary Treating Physician.” PR-2 indicates the Injured Worker “dispensed ”generic Flexeril. The dispensed medication reflects on -going treatment. As such, reimbursement For a PR-2 report is indicated

FCE, and X-rays: 73110, 72110, 73562, 73030 & 72040 fall under Medical-Legal Expenses

FCE, and X-rays: 73110, 72110, 73562, 73030 & 72040 fall under Medical-Legal Expenses as indicated in §9794 Reimbursement of Medical-Legal Expenses as these services were performed, not for treatment, but as part of the Medical-Legal evaluation.

Note: these services can be medical legal without a QME or AME depending on what the medicals state and FCE can, if the medicals reflect  be performed on the first visit but medicals have to state why.

·90837 -Psychotherapy, 60 minutes with patient and/or family member.·

 

E&M is performed on the same date of service as a major surgical procedure

The visit or service billed occurred within the global surgical period and is not separately reimbursable.”     If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57

Compound Medications: MPN Not to Dispense PBM:

2013: Express Scripts Ends Coverage for 1,000 Compound Drug Ingredients

Untimely Second Review: Waiver

Means that the defense cannot use an expert bill reviewer at Trial they waived that right.

Defective URs--

It is the obligation of the Adjuster to make sure all medicals in IMR request, failure to include all makes the IMR and UR defective, provider as an aggrieved party through himself  or herself can appeal the IMR to the WCAb as defective, it does not have to be through the injured worker like an IMR request is required too.

Example: IMR upheld UR denial of surgery, stating MRI  results were not in documents submitted --in this particular case it was obvious they were done (MRI), It was the obligation of the adjuster to make sure the MRI report was submitted. Therefore a defective UR and IMR subject to appeal without a lien to the WCAB by the provider or their representative The injured worker does not have to be involved in this appeal as opposed when submitting a IMR request. (any aggrieved party can appeal an IMR, a provider or  even if not a PTP provider can appeal a defective IMR)

Review of Medical Records:

Providers can bill for review of medical record if stated in the authorization even non-face-face, for medical legal bill as a supplement 101 if all medical records were not available at initial medical legal.

Plus one: Medical Legal:

When billing medical legal as PQME or AME attach PQME selection or AME agreement to billing, that is evidence  of authorization.

Plus two: Medical Necessity:

IMRs are very liberal for exceptions to the guidelines, as long as medicals show why exception warranted -- spend more time on medical reports

Plus Three: WC004 PR-4

WC004 PR-4 is reimbursed according to fee schedule at the rate of $38.68 for first page and $23.80 each additional page. Maximum of seven pages absent mutual agreement ($181.48).·Signed authorization reflects a per-determined CPT agreement to PR4 PTP report up to 15 pages. Payment for 99499 x 12 units of Record Review service provided for Injured Worker on 06/10/2014 was issued on 08/20/2014 by the Claims Administrator

 Plus Four: Petition for Non-IBR Medical-Legal Dispute,

Created for all medical-legal services even if not a PQME or AME, no lien fee required, no time limit for liens, no UR and authorization requirements, just proof the services were medical-legal -- definition of medical legal very liberal and encompass a lot of  services providers are not classifying as medical-legal -- one of the greatest tools under SB 863 and one of the least used or understood by providers.

Plus Five: Stop Billing 82486

Bill G0431 and all the 8000 codes Medicare stated were not bundled if services as performed warranted the same

Plus Six: EMG/NCV and Neurodiagnostic Testing 95913

CPT 95913, Nerve conduction studies; 13 or more studies,is listed on the Medical Fee Schedule. .AMA CPT 2011 Appendix J:If the nerves are listed in Appendix J... "as long as the testing is performed on different nerves or different branches on the list multiple units should be reported."

by: www.workcompliens.com

 

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Adjusters-Liens, Who are They, What Did They Do with The Old Adjusters

Saturday, June 13, 2015

7:17 PM

A long time ago, when I use to do collections, when I was first introduced to this industry, there was an adjuster who was more than fair. When I called her on an account, whatever she said you could bank on it that she was correct, sometimes paying more monies, sometimes not, but she had the know it all to know when additional payments were warranted and when not.

 

Through the years, I was always given the task of those difficult files, those going to the WCAB and recons, therefore my mind set was always on what the law stated and what it did not state, everything supported by the laws.

 

During those years, the majority of monies came from collections, that held little sense as to what should be paid and what not.  Sure, there were laws that were challenged ,won and lost, but bulldozing an adjuster and or defense attorney into settlements was common place.

 

Today, as I talk with adjusters, something changed, when I read a case put on by a lien claimant, that also changed. Adjusters today, are well educated in the laws, as are some lien claimants, with their skill level surpassing those of attorneys and sometimes Judges,  as they work themselves through the maze of complex laws.

 

I read a panel decision the other day, regarding sanctions against a lien claimant, and what she did was intelligent and well thought-out. She was sanctioned $2,500.00 for a missed hearing and then putting incorrect information in the response to NOI. Then in the recon, she owned up to her mistakes and laid out a plan to the WCAB as to why it would not happen again, the sanctions were reduced to $250.00, I was impressed.

 

I talk with adjusters, allowing leeway sometimes, sometimes not, some great, some not, but what is clear is that they are no longer buying misapplied laws and or misinterpreted laws that they were once victims of, of which this industry thrived on for collections.

 

Sometimes, I forget myself, as to what should be paid and what not, trying to stretch an interpretation of a law that cannot possibly  go that far and then I have to recheck myself, especially for adjusters who give fairness and deserve fairness in return.

 

I remember a few months back, I was doing an on location training for a collection company, and a collector, who had I known for many years and his skill level was above most. One day he turns to me from his desk, as if a lost child and said “what’s wrong with these adjusters today”, indicating why they were  not understanding what he was he was saying, that produced results for so many years, what changed.

 

What changed, is that those misapplication of laws that we used for so many years, that we swear was and is the law, was never the law, and because the education level of adjusters are excelling,  they have learned that well in the last two years. Some lien claimants picked that up quickly and adjusted in like kind, while others just cannot seem to understand the key that was never right but worked anyway, no longer fits the lock.

 

So we have still two segments of collections, the illogical, such treating on a UR denial and seeing that as a method to getting paid and second, the common sense of laws,  doing things correctly.

 

When resolving  a case or claim with an adjuster, listen to what they are saying and you will hear what is not spoken. Yes they are allowing settlements when violations of procedures are present,  but in the same act and underline words, they do say, "but this will not be the norm and be aware  strict compliance with laws is coming and those who use the short path will eventually hit a brick wall." Well, in fact, one adjuster just out right told me that, no silent words were used.

 

Treating on a UR denial and expecting payments of any kind, will eventually pass through the history of work comp collections, not surviving as a method to payments,  as we go towards the end on 2015, there exist no other path it can travel.

 

The last thing we want to do in 2015 is profess ignorance or attach the same to an adjuster, whether good or bad, with assertions of half-truths and misapplications of the laws, that time has definitely fell into history, which will no longer be repeated.

 

There are many laws that benefit providers under the umbrella of SB 863, and for some that door has yet to be explored, but it is there, and will eventually be the only path open.

 

by: www.workcompliens.com

 

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WC: Time to File Liens Expired, The Taste Of Default, Can It Be Fixed?

Thursday, June 18, 2015

10:27 AM

Insurance companies use to settle, even 10 cents on the dollar, if time to file a lien expired. We were told, go ahead and file liens even if the time to file expired and they could settle, without going in front of the WCAB Judge, so some relaxed   and let files fall into default. In 2015, one thing is consistent, adjusters and defense attorney will offer nothing on files past the time to file liens,  even if we actually filed one and it is past the time to file.

 

So here we are,  in 2015, with millions of providers receivables, with no pay and or little pay, outstanding that are past the time to file liens and are essentially non-collectable, even  those who have filed liens but are past the time limits.

 

The question  is, can they be saved, can payment be achieved   if payments were warranted and the answer is, yes and no. No, there is no mass magic formula to save these files, yes they can be  saved, but it is based on individual files and the substance of that file, which may not be attractive to some, so write offs may be a better path.

 

However, the point is, that some have leaned nothing from this, as presently liens are being filed for fee schedule issues alone  and medical necessity issues alone,  that are by law,  sanction able, but some defense attorneys will settle, so another path is being created that once again  may result in large defaults.

 

The point is, yes you use whatever window opens to resolve disputes, if someone is leaving it open, but you do not forget that it is temporary and the back end has to be fixed and done right, that is what we are missing. As each few months, these easy settlement methods, that has  allowed us to escape over organizing, will result in the same losses as we are seeing with files past the time to file and similar issues in which we are finding no redress, for dispute files that should have been paid..

 

by: www.workcompliens.com

 

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FRP (5 hours per day) at $1000 per day using CPT code 99499

Thursday, June 18, 2015

10:43 AM

 

 

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

99499

$3000.00

0.0

$3000.00

3

 

$2760.00

Order for Provider $2760.00

 

ANALYSIS AND FINDING

 

Based on review of the case file the following is noted: ·

 

ISSUE IN DISPUTE:

 

Provider is dissatisfied with denial of code 99499 x 3.

·

Claims Administrator denied code for three dates of service indicating on the Explanation of Review “Unlisted/BR svc not documented. Payment requires documentation explaining the service. See OMFS instructions for Procedures Without Unit Values.”

·

Documentation received included a Functional Restoration Program Authorization Request, Authorization and Reimbursement Agreement which states a request for additional 10 days/50 hours of OCPWC’s FRP (5 hours per day) at $1000 per day using CPT code 99499.

·

Letter dated May 5, 2014 from Claims Administrator’s Utilization Review Department approved Outpatient Functional Restoration Program for 10 days (50 hrs) for low back. ·

 

Provider submitted an FRP Team Conference Report documenting all the procedures performed with the injured worker for the three days for the Functional Restoration Program.

·

Based on the information reviewed, reimbursement for code 99499 x 3 is warranted.

·

PPO contract was received and an 8% discount is to be applied.

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2014_1201-1500/CB14-0001497.pdf>

 

 

Machine generated alternative text: Date of Senice: 642014— 662014
Functional Restoration Program
Workers’
Service Provider Plan Dispute  Multiple Comp N
Code Billed Allowed Amount  Surgery Allowed
99499 $3000.00 $0.00 $3000.00 3 NA $2760.00 DISPUTED SERVICE: Allow
reimbursement $2760.00

 

 

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WC All About Working Smart, Providers Organizing Their Practice Change

Sunday, June 21, 2015

6:34 PM

Below reflects  a few of the  processes Providers have to adopt. out of many, the below will produce results immediately, this week.

 

Under  SB 863 and all the laws that followed, providers should be treating  better, getting more treatment authorized and getting paid fee schedule with penalties and interest.

 

In fact, in 2015 Providers should have seen a great increase in receivables , penalties  and interest, lien fees back, IBR fees back and an increase in receivables that they have not seen for years .

 

It is no longer about more work, but smarter work,  which results in less expense , more treatment authorized and getting paid fee schedule. 

 

Providers are creating dispute files as liens, which are not lien cases and paying expenses that are  resulting in not getting paid fee schedule when these cases should have been easy  .

 

Here are just a few rules  of organization for a Providers' Office and lien companies ( there are many more but these are the most simple to adopt that will show results immediately, today):

 

1.  EORs do not reflect the history of the dispute .  An EOR may state , not authorized, but it was in fact authorized, therefore fee schedule and penalties and interest is what one should be paid, however because of misinformation or misleading information on these EORs, this is not happening.

 

  •  A provider cannot put in all disputes in one basket, i.e. those authorized and those not, most collection companies look at EORs and are not getting ( not getting information from provider)  which files were actually authorized,. Therefore, they  look at these EORs, and in a great majority of time it states not authorized when it was in fact authorized either, expressly  or by law, and then these companies are treating that file as a lien dispute, which now lost fee schedule recovery.

 

2.  Know which services that do not require authorization under E/M and or consulting but are under E&M  separable payments if correct modifier, simple monies, not a dispute file to the WCAB.

 

3.  Whatever one has to do, get the IMR decisions on your case,  those IMR decisions will tell you what you need to get the treatment authorized, and then you do a visit even if  within in 45 days (with payment for visit and report) get the report that they are asking for and or information and request authorization as a change in medical  documents facts related to the UR denials. Then a RFA  and get it authorized, even if treatment already performed, you get paid for doing this in addition, to now the treatment is authorized.

 

  • Example:  if they say 12 exceed the guidelines and UR upheld by IMR  because 12 exceeded the guidelines, I will put in an immediate RAF for  6, even if treatment  was already done, as a different request, now I get paid fee schedule and if functional improvement I get the other 6  authorized,  once again I get paid fee schedule.

 

  • Another example: so surgery maybe denied (UR denial, sometimes no reason, sometimes wrong or different guidelines cited than IMR) -- but then it goes to the IMR and they state UR denial up held because no MRI. So I get this decision, I will do a RFA for an  MRI and resubmit an RFA for the surgery based on new medical facts or if the MRI was done but not in the medicals submitted to the IMR, I appeal the IMR as not all medicals in (defective)  as it is the adjusters responsibilities and then get a second  RFA for the surgery and get it authorized IMR  with the MRI now in for consideration. The examples, go on and on, with many different fact circumstance, but all come down to the same conclusion,  getting treatment or services authorized is simple.

 

  • However,  lets get a little more crazy to make a point,

 

  • So the second IMR comes back and states, there was no showing of conservative medical treatment failed (usually they will state all issues within the first IMR, even with absent of the MRI , therefore  easy for a provider to correct, however to illustrate a point we will proceed as if they did not) ) , to warrant surgery, so I am going to call the patient in,  assess the treatment , if failed, document and request another RFA with the new medicals, if not, send for more conservative treatment Or if they state no psych clearance, I am going to call that patient  in, request a psych clearance  get it authorized as the IMR already told me it was necessary, then after the psych clearance get the surgery. And each time I called that patient in, it is billed even if within the 45 days as change in medical condition and or treatment as reflected by what these IMRs told me.(a little more to it as to consultation and possible E/M and prolonged services and additional testing and interpretation of those test, but none-the-less  payable (,i.e.  psych testing  modifier 59, plus consultation and report payment) -- possible medical-legal issues, ( but we will leave that for another day)

 

Here is the insane part, no tricks, no scheme, no short cuts, the Provider is getting paid to get the treatment requested resolved by following the IMRs, instead of treatment on a UR denial with little payment if any or  worse the patient goes without treatment, just about working smart.

 

However, then again,  staying in the dark does have its benefits, like the story below of the kid and the soda machine.

 

As some will state they get paid on UR denials, here is a new concept, how about getting paid fee schedule for the same treatment that you are treating on a UR denials.

 

 This applies to any service or product including, medications and compound medications, they state no random drug test or no exceptional factors for compound , call the patient in   and find if any, if not go the conservative treatment as recommended by the IMRs.

 

Now, this will surprise you, this process above, applies to initially denied cases and MPNs issues without liens and or time to file lines, to get treatment authorized or determined reasonable and necessary  and paid without the WCAB, this is the law under SB 863, which few, if any use, even without calling it a medical-legal (see below (end)) for more on denied injury and MPN issues.

 

  • I have found that most companies fight to get the RFAs from providers already submitted,  but they no do not fight to the actual UR decisions or IMR decisions, I cannot even put forth, why that makes no sense at all.
  • Here is the truly insane part, most have never even seen an IMR decision, the greatest tool for getting treatment authorized, 3 years in and yet some have never even read one, you have to get them

 

3. If the case is denied or an MPN  issue, spend more time with history of injury as that is  admissible in court to prove claim or show why treatment outside MPN was justified and you get paid for it, prolonged services face to face. ( no generic reasons, as MPNs are about facts to fit the laws, laws are great but nothing without the facts of why the injured worker went outside the MPN))

 

4, Know and understand what services are medical-legal even if not AME or PQME, this issue is missed in 80 percent of time in dispute files going to the WCAB..

 

5. Providers are not billing for all the services that they are allowed, but instead are using incorrect codes hoping to get it by bill review 1 of 10, while the law states 10 out of 10 if correct code.

 

  • It is like a running joke: so this boy was told that if he puts a quarter in the soda machine that was broken, that sometimes he can  get a soda that cost 50 cents. So this boy, for weeks, puts  25 cents  in the machine and no soda (no return of the 25 cents)  However, in the third week, he puts a quarter in and gets a soda,  happy he cheated the machine out of a 50 cent soda for 25 cents, even though  he lost ten dollars for all the other times he put 25 cents  in and nothing came out. 

 

6. Billing errors, major problem for providers today, substantial  monies lost.

 

  • IBRs have to be done, just have to accept that fact and make sure one wins on the IBRs by see other similar decisions
  • Do 2nd reviews, that will have some real impact and not just token monies.

 

There are many more simple changes that a Provider has to make, as 2015 is about applying  a surgeons' knife and not putting a band aid on everything that comes through the door

 

If one wants to see success:

 

  • look to those that file IBRs routinely ,
  • look to those that file "Petition for NON-IBR Medical Legal Disputes",
  • look to those that appeal IMR decisions (providers can appeal if all records not in decision, IMR will state what records were not included so the work is  done for you),
  • look to those reading these IMRs and then request the treatment and or additional testing  that was missing from the initial RFA -medicals,
  • look to providers who are going IBR on medical legals and
  • look to providers who understand the petition  for penalties and interest,
  • look to those who are looking at IMRs as instructions on how to get treatment authorized for that present patient , even when they upheld the UR denial,  they tell you what you need to request next to get to the treatment you want.
  • look to those who are getting lien fees reimbursed.

 

In 2015, everything has landed and providers who are working smart are  enjoying the benefits that are there , based on applying  the laws and decisions reflected  by the WCAB, IMR and IBRs. It is not about what insurance companies are doing but how providers respond and use the IMRs and IBRs and WCAB properly, that is where the solutions are.

 

In fact if set up correctly, liens would be seldom, even in denied cases or contested liability issues, if set up

properly, getting fee schedule and penalties and interest would be the norm.

 

by: www.workcompliens.com

 

 If Providers had magic glasses, that allowed them to see the simple monies they lost over the years, they would see the unbelievable and ask the  question no one can answer,  why they let it go on for so long. Here is the thing, these IBR decisions and IMR decisions, are one part of those magic glasses. Trust me, when I say all providers need to look through these glasses.

 

  Here is the summation, 2015 is a  game with many levels, one can play at the lowest level, getting adjusters to resolve and get upset with bad files or low settlements. Or go to the higher level and deal with the IMRs and IBRs,. becoming  an expert on  fee schedule based on IBRs and become  an expert in treatments and services with the IMRs and become an expert at the WCAB with WCAB decisions, rising above the garbage which  is  between the lowest level and highest level in 2015, which sometimes we have to deal with, but is not meant to be the norm.

 

Denied Cases or Contested Liability Issues:

 

Now, to understand how the above applies to denied cases or issues of contested liability i.e. MPNs etc.,, one has to understand that SB 863 mirrored other States, meaning once a case was determined comprehensibility then without other time limitations the IMR and IBR process time limits and applications starts anew, without limitation, as to say, lien time limits as defaults. However California differs from other states in that it has a "Compromise and Release", meaning a case can be resolved without a final determination of injury, therefore the  necessity of liens, while in other States an injury is ether, yes or no.

 

Therefore, to maximum the process in California one has to understand some basics, first applicant attorneys in the majority of cases, only  take on cases  that they know they can win, so regardless of a C&R most  cases have elements of an industrial injury and if one knows how to proceed on,  an IMR or IBR order can be had, even if no lien filed or past the time to file a lien.

 

Now, the same process applies to MPNs, with a slightly different twist, with the same results, in getting payments with out liens from the IBR and or IMR. but it  is more complex and beyond the scope of this post as it  would confuse most if put forth here in summary.

 

by: www.workcompliens.com

 

 In short,  3 years into SB 863 most have not yet mastered  or even applied correctly, second reviews or IBRs, which are a very small but important part of SB 863, therefore mastering other levels of SB 863 appears impossible for some, but it's there and has to be applied. When I hear those that complain about SB 863, I know they only see what insurance companies are doing, and not seeing all the  procedural and enforcement laws under SB 863 that benefits them which overshadow what insurance companies may or may not be doing.

 

 We are many years past the point where Providers should be mad as hell and start putting their hands in the mix of receivables to  get it right, well past that time.

 

Pasted from <https://www.linkedin.com/pulse/wc-all-working-smart-providers-organizing-practice-change-boggan-jd?trk=mp-reader-card>

 

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WC: Are Providers Under-treating Injured Workers? Data Shows they Are

Sunday, June 21, 2015

6:50 PM

Indeed, a strange title for a paper, when one is accustomed to seeing studies stating; “Providers Over Treating” and or “Injured Workers are Getting Inadequate Medical Care”.

 

First to understand this paper, understand that we are not addressing the minority of Providers who may have abused the system in the past, as no matter what profession exists, there are and will always be a portion who abuse the system, and that is not what we are focusing on today.

 

My father was and is an orthopedic surgeon and the most honest man anyone could possibly meet, who practiced industrial medicine for a number of years. I can guarantee, that when he treated an injured worker, the treatment was reasonable and necessary and for the benefit of his patients. However, in his  retirement, he saw millions of dollars in accounts receivables disappear over the years, that were written off by a collection management company and he never understood why. One time he stated to me, that he did not understand this “workers' comp”, “only place you can do the work, and not get paid”.

Prior to the adoption of the IMR (Independent Medical Review) process, that reviews denial of medical necessity issues by insurance companies, essentially,  the only experts were the URs and the medical legal providers who would comment on  medical necessity issues, very limit knowledge base and very limited application of the treatment guidelines.

 

Most Providers, (now when I say this, get the few who have abused the system out your head,)  are trying to help an injured worker and know the responsibility in helping the patient with pan, utilizing their skill and educational level they acquired through the years.

 

We have great Providers in Work Comp today, who will make sure their patients get the required treatment, who know what treatment is required and will call insurance company reviewers to make sure all the facts and medical evidence is understood , and they make sure their medical reports are complete for the IMR reviewers. I know this,  because, when I get a dispute file I get to read their medical reports, in fact, I love psych reports because they are very detail, when I see a psych report in a dispute file I get excited, as I know all the information I need to prevail in that case are in those reports, as is most surgeons and many other Providers ( AMEs and QMEs).

 

Decision rationale: Oxycontin is a long-acting opioid used to stabilize medication levels and provide around-the-clock analgesia to patients with chronic pain. According to the MTUS the use of opioid pain medication appears to be efficacious but limited for short-term pain relief and long-term efficacy is unclear (>16weeks), but also appears limited. For on-going management of a patient being treated with opioids the MTUS recommends that prescriptions from a single practitioner are taken as directed and all prescriptions are to be obtained by a single pharmacy. The lowest possible dose should be prescribed to improve pain and function. Ongoing review and documentation of pain relief, functional status and appropriate medications use and side effects be documented at the time of office visits. Intermittent urine toxicology should be performed. The medications should be weaned and discontinued if there is no overall improvement in function, continued pain or decrease in functioning. In this case the patient is under the care of a pain specialist. His pain is adequately managed by the current doses of oxycodone and the patient does not have any adverse side effects. It is documented that his function is improved with the use of the pain medications and he is being properly monitored with frequent visits to his provider (follow up is planned in 4 weeks) and urine toxicology testing. The continued use of long acting OxyContin is medically appropriate.

 

Then we have  others, that  when I see their medical reports I know the case is essentially lost, unless I can find some other  medical report ( that is usually when I look for a psych report to save the case) , because that medical report deprived me of all the information I needed to prevail in that case.

 

Decision rationale:The clinical documentation submitted for review does indicate that the patient reports functional pain control with the patient's current medication usage. California Medical Treatment Utilization Schedule (MTUS) recommends the continued use of opioids in the management of chronic pain be supported by documentation of objective pain relief, assessment of side effects, objective evidence of functional benefit, and monitoring of compliance to the prescribed medication schedule. The clinical documentation submitted for review does not provide evidence that the patient's pain relief has been objectively assessed. Additionally, there is no documentation of significant functional benefit as a result of the patient's medication usage. Also, there is no recent evidence of monitoring of compliance to the patient's prescribed medication schedule. Therefore, the continued use of OxyContin is not supported. The request for Oxycontin 80mg #150 is not medically necessary and appropriate

 

I detest template medical reports, as most are the same, " Patient just completed  12 therapy visits, and doing fine, so I am requesting shock wave, 12 more visits therapy, FCE and some NCV testing  and lint therapy",  (why, to find out why they are doing well?) -- unfortunately, that was not an exaggeration.  In fact the  additional 12 would get authorized if objective functional improvement documented, the FCE could be authorized if provider documented why at the early stage of treatment, the other requests would require more documented facts and justification. But, as far as using that medical report in court or to resolve a dispute such as MPN and denied case  later admitted , the report has no value in fact negative value.

 

Then we have this group of Providers, that are great in their profession, but are very poor in documenting medical information for URs and IMRs and haven’t changed for years These Providers, believe that no matter what they do, insurance companies will not treat them fairly. In addition, for some reason, they believe if they did everything proper, their practice would not survive,  as the UR denials and IMRs upholding, which  would in their minds, turn away half of the treatment they provide today. Now, this is where they are not connecting the dots, first insurance companies are the not the final say in medical necessity, but the IMRs are, and they are  extremely fair (kept that mind open now).

In fact, a provider has the MTUS, the ODG, The ACOEM guidelines  and any published medical journal on medical necessity of treatment issues, so we do have a wide selection to justify treatment and or services.

 

So, I must have read over 10 thousand IMR decisions or more to date, over the span of time that  I have been in workers comp, I have probably read as many medical reports,  UR denials and or issues of medical necessity, and or denied claims.

 

Now, here we go with that right state of mind again, in the majority of the time, on UR denials and IMRs upholding or providers treating on UR denials or forging treatment and or medications , including compound medications, they are actually   reasonable and necessary, this I get from reading over 10 thousand IMR decisions.

 

Very seldom, is a UR denial and IMR upholding because the provider was requesting treatment and or services way out of line ( although there are cases) but because they failed to document what the guidelines require, or if outside the guidelines what documented exceptional factors requires them to treat outside the guidelines. If a Provider believes compound medications is the miracle drug for all patients, great, then show the exception to the guidelines that match the treatment provided to the injured worker, some have done it and are doing it today i.e.( from IMR decision “…discussion detailing extenuating circumstances that would support this use of this compound product in this setting…”

 

Therefore, in short, a provider treating on UR denials are essentially just accomplishing  low payments and unnecessary litigation, which in turn results in under treatment. The reason it results in under treatment and for that matter lack of necessary pain medication, is  because the succession of treatment required for the injured worker cannot be communicated correctly to UR reviewer nor the  IMRs reviewers,  so the injured worker is going without  the more time consuming treatment and expensive treatment, as most will not treat on those  UR denials. FRP is an example and so is spinal or other types of surgeries

 

In fact, denied cases later admitted, MPN issues or any other issue that one takes a case on a lien bases, the medical necessity of the treatment in its finality  of  resolving  those cases is becoming essential and will be mandatory very shortly.  For those who do not understand this will have millions of dollars on the books that will disappear as non-collectable, that is a real fact.

 

So, yes providers are under treating injured workers and in fact, are under paying themselves, the data of the IMRs are clear, one cannot  change that. A collector stated that a provider did 108 therapy sessions and expected them to collect on it,  maybe, that is way out of line or maybe there were extenuation of facts that warranted 108 outside the guidelines, but because the provider never documented why , no one will ever know.

 

by: www.workcompliens.com

 

 The sad finding is that, those who treat on UR denials are not cheating the system, but cheating themselves, because a change of a few documented facts and understanding of what  these IMRs are looking for, probably would make that same treatment authorized and payable. In cases initially denied and  later admitted , MPN issues or any other contested liability issue, it is also a protection when lien filing , as orders could be had from the IMR even after the time to file a lien has expired, a win win all the way around.

 

 

Pasted from <https://www.linkedin.com/pulse/wc-providers-under-treating-injured-workers-data-shows-boggan-jd?trk=mp-reader-card>

 

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2015 Collections, Exhausting to Explain, So Let Me Make it Simple

Tuesday, June 23, 2015

9:06 AM

In 2013, three (3) EORs floated around from provider to collection company, which showed 82486 paid at approximately, $1,300.00, because of these 3 EORs (only 3) , most changed their billing code from G0431 to 82486 based on 3 EORS with stories of riches behind them, millions lost.

 

So here we are in 2015, three years into SB 863 and the same concept of following the path of lost monies is again showing its head, as it  has several times over the past  4 years, with  the end result to substantial losses for Providers.

 

The rules  are clear, a Provider does not do certain procedures timely or  correctly,  one does not  get paid, so at this point, the losses by Providers are almost consensual  in nature,  eyes wide open.

When I consult with a providers' office I presume, because we are three years in, that they know a little about SB 863, at a minimum the following:

 

  •  what a proper second review is,
  • that they know how to appeal a defective UR and IMR,
  • that they know how to petition for penalties and interest,
  • that they know how to respond to a notice of transfer into an MPN,
  • that they know how to do an IBR,
  • that they know how to get an order for payment without a lien on a contested liability issue,
  • that they know how to request the right treatment based on what an IMR instructed them to request,
  • that they know how to do a retrospective review for the treatment they provided with new medical information,
  • that they know how to determine if their services are medical legal,
  • that they know how t do a"Petition  for a Non-IBR Medical Legal",
  • that they know that even when showing a defective UR they have to show medical necessity.
  • that they know how to get a lien fee back
  • how IBRs are ruling on PPO issues , when they apply and when not
  • how to give hearing reps a good case.
  • who is benefiting from IBRs and common mistakes
  • etc.,

 

To my continual  surprise,  this is not the case, except for a very few providers.  Therefore, for Providers, I will tell you how to fix the sins of ignorance of the above that have and are resulting in losses.

 

Now I am addressing Providers, as hearing reps are doing their job, finding that novice  Defense Attorney to resolve cases that should not be paid and they are good at it, but that does not reflect what the law is, that is their skill level.

 

I am not addressing the information you get from collection companies, as their job is tell stories of impossible tasks overcome. Highlighting their skill level above others and to give a Provider hope with a wait and see, as things will get better. That is  their task and function, with hope of new methods and plans,  but that is not the law either, .just good PR, that we all do.

 

So, disregard all of the above, and the one thing a Provider has to do, to forgive all sins of ignorance of the new laws and missed laws, whether an admitted injury, denied injury and or whatever the issues in the case, is treat within the guidelines and  or justify the treatment in the medical reports even if treatment is outside  the guidelines, that's it and then everything is simple. Below is what treating within  the guidelines does for a provider (putting aside medical-legal for now):

 

  1. A Provider gets paid fee schedule
  1. If defective or untimely UR, end results if treatment not within guidelines no payments.
  1. If defective UR / IMR and appeal will, win on appeal  if treatment within guidelines paid fee schedule.
  1. If denied case or contested liability issues, are  resolved by court order,  no lien and a retrospective is   required by adjuster, will get an IMR order if treatment in guidelines ( can be another lien claimant overcoming an issue, an expiated hearing or the C&R, but to use the C&R as a order resolving a contested issues, wording extremely important) , no lien or time to file liens required.
  1. Can do a retrospective review if missing documents and get a on order for payments.
  2. MPN issues, main issue was that treatment not offer so half the case is that your treatment was  within the guidelines.
  3. Essential for both admitted and denied cases to get orders for payments without liens or time to file liens.

 

There are several more benefits  to treating within the guidelines, but we will start with the above to kept it simple. If a provider masters the Guidelines, which is fairly simple, they will see fee schedule more often, and 10 cents on the dollar a thing of the past, then hearing reps and collection companies can do what you pay them to do, if you have the good ones.

 

by: www.workcompliens.com

 

Pasted from <https://www.linkedin.com/pulse/2015-collections-exhausting-explain-so-let-me-make-simple-boggan-jd?trk=mp-reader-card>

 

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Some Providers Reading the Playbook Getting it Right, Others Same Old

Monday, June 29, 2015

10:24 AM

I was in the process of mapping out injuries within the  treatment guidelines,  to show that more treatment is warranted under the guidelines  than what most Providers are providing and or are aware should be provided. Thereby demonstrating; that  injured workers are being denied treatment, not because of the IMR, Guidelines, or insurance companies, but because of non-adherence to the guidelines   

 

Now, to map out all the possible;  treatment, services, testing, medications surgeries, pain management, psych, pain  and return to work programs,  that may be available to an injured worker, based on the type of injury, takes more than just reading the guidelines as we have the MTUS, ODG, ACOEM and more. The IMR (Independent Medical Review) decisions allows me to see and apply how those rules (Guidelines)  are applied in real factual circumstance and therefore the application of the guidelines are showing, i,e, responding to treatment, what next and what must be shown, responding negatively, go here, if responding positive, go here, showing exception to the guidelines, etc.

 

My present project was for an industrial  back injury, although most injured workers suffer from multiple body parts injuries, for the purpose of this post we will address the back  as a sole injury, in order to make it simpler to understand.

 

I have read and mapped out thousands of IMRs, paying particular attention to   newly posted IMRs, to see if there has been a change in the industry or not.

 

I was encouraged to see in the last few months, a noticeable increase in the number of lumbar epidural steroid injections that were initially denied UR then the IMR overturned and found them medically necessary, which is an indication that some providers are getting it and adjusting well.  However,  then we had most other services unchanged, where simple errors are still a common story in these IMRs upholding.

 

Through the years, I cannot even estimate the number of disputed  files I was involved with and or assessed , tried at the WCB  and consulted on. However, what I can tell you is, that in all my years I have never seen one dispute  file or any file that even came close to providing  all the treatment that the guidelines state should be available to an injured work, not even close.

 

We have many great  Providers in this industry, and my intent is not to diminish  what they stood for for all these years of doing things right, when right wasn't as profitable, These providers are indeed champions for the injured worker and decisions of justice are posted everyday as they get IBRs to award reasonable payments and as they get UR denials overturned, finding a easier path in achieving justice.

 

However, for others, when did this turn  into a money machine with  our main objective  treating  as much as possible without looking to guidelines because we believe adjusters will always settle.  If the IMR process creates  a trend that Providers are more aware of the guidelines and all the treatment and services available to an injured worker, then more power to the IMR system.

 

So a provider is requesting Post Op PhysicalTherapy 2 x6Lumbar Spine. now the  guidelines state up 34 post surgical visits of therapy for a lumber fusion is recommended, however because the provider did not show  by documentation of functional improvement or out come of 16 prior sessions the services were denied, how could a provider not see that coming.

 

Like any process of medical treatment, private, etc, the appeal process is meant  to ensure that the patient is not being denied treatment. The IMR process is supposed to be the champion for injured workers when reasonable treatment is denied, not the champion of insurance companies. However, if  our appeals do not have the correct information justifying the treatment, it fails to work as it was designed to work, as we are seeing today.  Just like the IBR process, it was designed to ensure Providers get paid reasonable, a check and balance for carries who fail to pay within the rules, but it has to be used correctly.

 

In short, we have tools that were designed to bring forth justice, when justice is lacking, and although it requires detail it does exist. Whether  the system could be better, maybe, but it is what we have and ignoring it does not bring about what treatment should be provided to an injured worker, nor does ignoring it bring about reasonable payments.

 

Everyday, new and differing decisions are taking place that have to be incorporated, like restarting a computer to get updates every so often, like it  or not, that is where we are, until it settles down, which may be many years, so keeping up is indeed a challenge. SB 863 is not a game for fools without a heavy price, both for the injured worker and  for payments to a Provider.

 

  • Example: it use to be IBRs were consistent in when they applied PPO discounts and when not, however,  lately there has been a clear inconsistency of decisions regarding this issue. Therefore, the appeal process of IBRs has to take place so that we know the rules, knowing the rules allows one to make the correct decisions, not knowing and or getting inconsistent decisions always results in unnecessary losses.So if one did not get this update and they are flooding IBRs with PPO issues the decisions may not be  what we saw prior. For some, this is  good news, as they did not get the first update, that IBRs were disallowing PPO discounts, both showed losses for providers.  We have seen that with G0431  or 82486 where no Provider has sought an appeal and or  outside the IBR process, i.e.  a WCAB decision, and we know those results.

 

Are some of the objections and denial taking advantage of some Providers' lack of organization, absolutely , and if that is indeed the case, then the solutions have to be obvious to those who are the victims. Being right and showing we are right has never been easy, especially  when monies are involved either,  indirectly i.e.,   treatment or directly, payments, however walking over that  which may bring about fairness as if it did not exist, well, we are seeing the results of that to a degree, in 2015.

 

Insurance companies  are a profit business, and although some may say they have gone too far under SB 863, it doesn't help, things will not change. And in response to insurance companies being conservative in allowing treatment and payments (some may want to use stronger words), it is the Providers who are supposed to take the role of champions for injured workers and show the IMR that treatment was denied  unreasonably  and show the IBRs that payments were not paid reasonable and show the WCAB the injustice of denials, and not to accept and lay down for 10 cents on the dollar and or no payments, or treating on UR denials with no payments.

 

There is no doubt that all providers are suffering losses. all types, it does not matter, as all have been put in one basket, fair or not.  But the good news is that some   Providers are getting it and adjusting, as well as are some collection companies,  which in turn will offer more treatment to injured workers as shown in the guidelines. To bring forth injustices into the light, has never been easy, and it is great to see some Providers are doing that as a trend as some providers are  getting more UR denials overturned.

 

There are stories told by Providers and insurance companies alike, each story of abuse can be matched by a story of the other, that could take a place in the books of the strange and unusual. However, to the individual injured worker, all that means nothing, all they want is what the system is supposed to produce, medical treatment to cure and relieve  the effects of an industrial injury and for Providers, getting that for them, requires more than complaining about the system. or being justified in taking shortcuts.

 

In short, working within the system is not easy and in fact extremely difficult when compared to what we had before, however by now one has to know it is extremely harmful not to.

 

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WC:101 Billing Errors, These are Just a Few, Causing Disputes 0 Payments

Monday, June 29, 2015

2:06 PM

SB 863 gave us a lot, but one of the main important tools they gave, was the ability to see mistakes on billing, and authorization, through IBR decisions and IMR decisions.

 

With most not adapting well to SB 863, nor  many using the IBR process or second review process correctly , these billing errors are going into dispute files instead of being paid in initial billing.  The end result is of 0 payments and into time line defaults, forever not payable. Therefore, for providers who do not use the IMR or IBR process properly, they at least have to master correct billing.

 

Not only are providers cheating themselves in billing by simple mistakes, but in addition, injured workers are not receiving  all the treatment, services and or medications under the ODG, ACOEM, MTUS and published medical journals, that are in fact stated in IMR decisions, that injured workers should receive   Therefore, in short, for some providers, not only are they billing incorrectly, but are also not providing or billing for all services that are reasonable necessary under the guidelines.

 

For today's paper we will show  over 101 billing errors,  from simple modifier exclusions, to submitting  a RFA as proof of authorization, to DRG 003 being awarded over $289,625.94 above fee schedule in the addition to the  amount already reimbursed of $435,110.19

 

  • 99354 -Prolonged service
  • Billing ML104-95 can be billed with 96101
  • 97113 is paired to billed code 97150, Group Therapeutic Exercise. ·
  • Based on NCCI Edits, generally codes 99205 and 96101
  • PR2 does not clarify if medication was dispensed
  • 0232T has a listed Multiple procedure (Modifier 51) indicator:
  • G0390 is separately reimbursable and not included in another service.
  • CPT 82055, 82150, 80048, 85025, 85384, 85610 and 85730 are separately reimbursable
  • The code descriptors for CPT codes 20670
  • Consultation reports requested by the Qualified Medical Evaluator (“QME”) or Agreed Medical Evaluator (“AME”)
  • Dispense” means ML 101 -Follow-up Medical-Legal Evaluation
  • WC004 is a California Specific Code
  • ML 105 -Fees for medical-legal testimony.
  • Per NCCI Edits mentioned, generally codes 97150 and 97113 are not billed together.
  • Based on the NCCI edits The following code pairs generally cannot be reported together: 94761 and 99285;
  • 99285 -Emergency department visit
  • §9789.16.5 Surgery –Multiple Surgeries and Endoscopies
  • ( DWC states, “The purpose of the 45-day rule
  • Based on the NCCI edits the following code pairs generally cannot be reported together: 90471 and 99205; 90471 and 99213; and 99205 and 9913.
  • As code pairs exist between 96374 and 27818 as well as 96375 and 27818, generally these codes are not reported together
  • : 81002, 82570, G6040, G6039, 80500, G6036, 80184, G6037, G6053, G6034, G6032, G6030, G6052, G6031, G6045, G6046, G6043, G6056 & 83789
  • § 9789.12.4 “By Report” -Reimbursement for Unlisted Procedures / Procedures Lacking RBRVUs.
  • Physical Medicine/Chiropractic/Acupuncture Multiple Procedure Payment Reduction;
  • NCCI edits state that generally 97140
  • 97113, is paired to billed code 97150, Group Therapeutic Exercise.
  • Pursuant Surgery Rule #7,
  • CPT 26785and 26746; and 26785 and 29130.
  • More

 

 99354 -Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service); Use 99354in conjunction with 90837, 99201-99215, 99241-99245, 99324-99337, 99341-99350

 

Billing ML104-95 can be billed with 96101

Billing for psychology testing with a medical-legal or E&M is causing major problems with providers billing, the are payable  ( for E&M no modifier  and lack of documented tome appears to be major issues)

 

OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”

§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.

 

 

97113 is paired to billed code 97150, Group Therapeutic Exercise. ·

NCCI edits reveal 97150 is Colum 1 Code when billed with Colum 2 Code,

97113.·Under certain circumstances, the paired codes in question may be unbundled with the use of modifier -59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.” ·

 

 

Based on NCCI Edits, generally codes 99205 and 96101 are not billed together. However, Modifier Indicator column shows ‘1’which states if an approved modifier is appended to the correct CPT code, and supporting documentation accompanies use of the code then the edit may be overridden. ·

 

Major issue today for; procedures, medications and DME, medical reports are not documenting that medications were dispensed, procedure was performed or DME was dispensed to injured worker.  allow 0 pay for those mistakes

 

PR2 does not clarify if medication was dispensed or if a prescription was written for the Injured Worker.

 

 

0232T has a listed Multiple procedure (Modifier 51) indicator: “0.” Multiple Procedure Payment adjustment is not applicable. ·Assigned Status Code for 0232T is ‘C.”·§ 9789.12.3 Status Codes C, I, N and R

o(a) Except as otherwise provided in this fee schedule, for physician and non

-physician practitioner services billed using Current Procedural Terminology

(CPT) codes, the RVUs listed in the Centers for Medicare and Medicaid Services

(CMS’) National Physician Fee Schedule Relative Value File will be utilized

regardless of status code.

b) When procedures with status indicator codes C, N, or R, do not have RVUs

assigned under the CMS’ National Physician Fee Schedule Relative Value File,

these services shall be reimbursed By Report.

·

 

G0390 is separately reimbursable and not included in another service.

·

G0390 is a valid code with a relative value with a status indicator of

“S.” Status indicator ‘S’ indicates a separate APC payment is

allowable. Reimbursement warranted for HCPCS G0390.

 

 

CPT 82055, 82150, 80048, 85025, 85384, 85610 and 85730 are separately reimbursable in accordance with Title 8, California Code of Regulations, §9789.50 Laboratory Fee Schedule. Reimbursement is warranted.

 

 

The code descriptors for CPT codes 20670 (removal of implant; superficial...) and 20680 (removal of implant; deep...) do not define the unit of service. CMS allows one unit of Service for all implants removed from an anatomic site. This single unit of service includes the removal of all screws, rods, plates, wires, etc. from an anatomic site whether through one or more surgical incisions. An additional unit of service may be reported only if implant(s) are removed from a distinct and separate anatomic site.

 

Consultation reports requested by the Qualified Medical Evaluator (“QME”)

or Agreed Medical Evaluator (“AME”) in the context of a medical-legal evaluation. Use WC007, modifier -30

 

Pursuant to The General Information and Instructions, § 9792.5 Payment for Medical Treatment: (4) “Required report” means a report which must be submitted pursuant to Section 9785·Provider resubmitted the CPT 99214 claim along with only a chart note

.

 

 

Dispense” means the furnishing of drugs upon a legal prescription from a physician, dentist or podiatrist.·

·

ML 101 -Follow-up Medical-Legal Evaluation. Limited to a follow-up medical

-legal evaluation by a physician which occurs within nine months of the date on which the prior medical-legal evaluation was performed. The physician shall include in his or her report verification, under penalty of perjury, of time spent in each of the following activities: review of records, face-to-face time with the injured worker, and preparation of the report. Time spent shall be tabulated in increments of 15 minutes or portions thereof, rounded to the nearest quarter hour. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary fee, whichever is less, for each quarter hour

 

WC004 is a California Specific Code as a Permanent and Stationary Report (P & S report). First page $38.68 and $23.80 each additional page to a maximum of 7 pages.

 

Example: CMS 1500 form reflects 96101-93 x 12 units (line items) billed with Evaluation and Management Code 99205. ·CMS 1500 form reflects 96116 x 2 units (line items) billed with Evaluation and Management Code 99205.

·

Based on the NCCI edits, a code pair exist between CPT 99205 and 96101 as well 99205 and 96116.

·

Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation supports the use of the procedure code, then the edit may be overridden. ··for CTP 96101 and 96116. Valid Modifiers for 96101 and 96116 are: 25, 27, 50, 52, 58, 59,

73, 74, 76, 77, 78, 79, 91

E1, E2, E3, E4, F1, F2, F3, F4, F5, F6, F7, F8, F9, FA, GG, GH,

LC, LD, LM, LT, RC, RI, RT, T1, T2, T3, T4, T5, T6, T7, T8, T9, & TA.

·

ML 105 -Fees for medical-legal testimony. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician. The physician shall be entitled to fees for all itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time. The physician shall be paid a minimum of one hour for a scheduled deposition.

 

·Per NCCI Edits mentioned, generally codes 97150 and 97113 are not billed together. However, Modifier Indicator column shows ‘1’ which states if the correct code has an approved NCCI modifier appended, and documentation is submitted to support code used, then the edit may be overridden. Modifier -59 is an approved modifier and may be used to support billed code 97113

Based on the NCCI edits The following code pairs generally cannot be reported together: 94761 and 99285;

·

Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation supports the use of the procedure code then the edit may be overridden.

·

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI edit include:

·

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI

·

Global surgery modifiers: 24, 25, 57, 58, 78, 79

·

Other modifiers: 27, 59, 91

·

99285 -Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status:

A comprehensive history;

A comprehensive examination; and Medical decision making of high complexity.

·99285 has a status indicator of V -Clinic or Emergency Department Visit Paid under OPPS; separate APC payment

 

Example:

9354 Prolonged Services With Face-to-Face Contact performed on 12/10/2014

.·Claims Administrator based the denial on the following rational: “No payment was made because the value of the services is included within the value of another service performed on the same day.”

·EOR reflects 99213 Established Patient (15min) reimbursement.

·

PR2 reflects 99213 Established Patient (15 min) documented.

·PR2, entry next to “Date of exam, "indicates “Time spent with patient 1 hour and 12 min.”

·

CPT 99354 Code Definition: Prolonged services, first hour, face-to-face. Report indicates 99213. 99213 Codes Description time element is 15 min. ·

15 min –64 min = 57 min meeting the criteria for 99354.

·

Based on the aforementioned documentation and guidelines, pursuant to Title 8 CCR §9789.11(a)(l) General Information and Instructions, Prolonged Services

, reimbursement is warranted for 99354 x 1 unit.

 

§9789.16.5 Surgery –Multiple Surgeries and Endoscopies

·(d) Determining Maximum Payment for Endoscopies

·The Multiple Procedure (“Mult Proc”) column of the National Physician Fee Schedule Relative Value File contains a “3” to indicate procedures that are subject to special rules for multiple endoscopic procedures. For each endoscopic procedure with an indicator of “3”, the Endoscopic Base Code (“Endo Base”) column indicates the related base endoscopy code. Those codes that share a base code are in the same “family” and are “related.”

·Two codes billed: Endoscopic procedure and related base endoscopic procedure billed·If an endoscopic procedure is reported with only its base procedure, the base procedure is not separately payable. Payment for the base procedure is included in the payment for the other endoscopy

 

 DWC states, “The purpose of the 45-day rule in California Code of Regulations, Title 8, section 9785(f)(8) is to make sure that in the case of continuing treatment, that the patient’s progress is monitored no less than once every 45 days.” However, “Within a 45-day period, the primary treating physician can bill for as many PR-2’s as are medically necessary.”

Based on the NCCI edits the following code pairs generally cannot be reported together: 90471 and 99205; 90471 and 99213; and 99205 and 9913.

·

Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation supports the use of the procedure code then the edit may be overridden.

Based on the NCCI edits the following code pairs generally cannot be reported together: 90471 and 99205.

·

Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation supports the use of the procedure code then the edit may be overridden.

·

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI edit include:

·

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI

·

Global surgery modifiers: 24, 25, 57, 58, 78, 79

·

Other modifiers: 27, 59, 91

 

As code pairs exist between 96374 and 27818 as well as 96375 and 27818, generally these codes are not reported together

. However, Modifier Indicator column shows ‘1’ which states that if an approved modifier is appended to the appropriate CPT code, and documentation is submitted to support the code billed, then the edit may be overridden.

·

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI

 

Additional Awarded: 81002, 82570, G6040, G6039, 80500, G6036, 80184, G6037, G6053, G6034, G6032, G6030, G6052, G6031, G6045, G6046, G6043, G6056 & 83789

 

IBRs have been a little consistent as to PPO contract applications sometimes they apply the discount, sometimes not,  but there has been a flood of decisions on PPO discounts taken and ordered allowed and some not allowed, see all decisions.

 

Example:

PQM report indicates the following timing:

·Face-to-Face with applicant (history and mental status exam):4 hours

·Record review and review of prior reports and significant commentaryon medical records:8 hours

·Report Prep Time:12 hours

·Total time: 24 hours

·3 Hours are subtracted from the overall time as 96118x 1 unit and 96101 x 2 units are “per hour codes”and the value of the Physician’stime is included within the relative value of each code.Total Revised Time: 21 hours/84 Units

 

Example:  Documentation regarding start and end times for the Aquatic (97113) and Group(97150)sessions not indicated on the flow sheet. As such, IBR not able to determine if the two paired procedures were performed at “different timed intervals.

 

Example:  Based on NCCI Edits, generally codes 99205 and 96101 are not billed together. However, Modifier Indicator column shows ‘1’which states if an approved modifier is appended to the correct CPT code, and supporting documentation accompanies use of the code then the edit may be overridden. ·Provider did not bill code 96101 with a modifier and therefore was billed improperly and does not warrant reimbursement

Example:

Provider billed CPT 96374 -Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

·Documentation submitted does not mention substance or drug used and therefore reimbursement is not warranted.

 

·Provider also billed code 96375 -Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)·Again, documentation does not describe a substance or drug for this code and therefore reimbursement is not warranted.

 

·SPT 96361 -Intravenous infusion, hydration; each additional hour(List separately in addition to code for primary procedure)

 

·Documentation submitted does not mention a start and stop or total time intravenous infusion was administered. Therefore,reimbursement for 96361 is not warranted.

 

§ 9789.12.4 “By Report” -Reimbursement for Unlisted Procedures / Procedures Lacking RBRVUs

(a) An unlisted procedure shall be billed using the appropriate unlisted procedure code from the CPT. The procedure shall be billed by report (report not separately reimbursable), justifying that the service was reasonable and necessary to cure or relieve from the effects of the industrial injury or illness. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort and equipment necessary to provide the service.

 

Pursuant Chapter 4.5 Division of Workers’ Compensation, subchapter 1. Administrative Director –Administrative Rules, Article 5.3 Official Medical Fee Schedule, §89.15.4. Physical Medicine/Chiropractic/Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for Specified Procedure/Modality Services: (2) many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The MPPR applies to the Practice Expense (“PE”) payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures. Full payment is made for the unit or procedure with the highest PE payment. Full payment is made for the work and malpractice components and 50 percent payment is made for the PE for subsequent units and procedures, furn

No evidence that over 50% of the visit was spent counseling or coordinating care and what that content of counseling/ coordination entailed. Documentation stated only “45 minutes.

 

1995/1997Evaluation and Management Levels/Elements (History / Exam / Medical Decision Making), Established Patient:

99212: Problem Focused / Problem Focused / Straight Forward

99213:Expanded Problem Focused / Expanded Problem Focused / Low Complexity

99214:Detailed History/ Detailed Exam/ Moderate Complexity

i.History 3 Chronic Conditions or Greater than 4 elements relating to: quality,location,duration,severity, timing, context modifying factors, & associated symptoms.

ii.Detailed Exam

iii.ModerateComplexity

Pertinent PMFSH related to the patient's problems

 

99215 Comprehensive: extended HPI, ROS that is directly related to the problems identified in the HPI plus all additional body systems, and a complete PMFSH.

Time:In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. The total length of time of the encounter (faced-to-face) should be documented and the record should describe the counseling and/or activities to coordinate care

.

 NCCI edits state that generally 97140 and97530are not reported together. However, Modifier Indicator column shows ‘1’ which states if the appropriate modifier is appended to the correct code, and proper documentation is supporting the code, then the NCCI edit may be overridden

 

97113, is paired to billed code 97150, Group Therapeutic Exercise.

·NCCI edits reveal 97150 is Colum 1 Code when billed with Colum 2 Code, 97113.

·Under certain circumstances, the paired codes in question may be unbundled with the use of modifier -59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.

 

Pursuant Surgery Rule #7, multiple surgical procedures performed at the same session is calculated as follows: Major (highest valued) procedure: 100% of listed value; Second highest valued or equivalent procedure: 50% of listed value; third highest valued procedure: 25% of listed value.

 

CPT 26785and 26746; and 26785 and 29130.

·Modifier Indicator column shows ‘1’ which states if a proper modifier is appended to the correct code and documentation supports the use of the procedure code then the edit may be overridden.

·Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI edit include:·Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI·Global surgery modifiers: 24, 25, 57, 58, 78, 79·Other modifiers: 27, 59, 9

 

Example: Code 0232T·Claims administrator reimbursed $71.09 indicating on the Explanation of Review “Reimbursement is based on the applicable reimbursement fee schedule.”·Per PPO contract received, under Appendix B Fee Schedule for First Health Products, II Workers’Compensation Product B: Reimbursement for services that are billed with aprocedure code for which there is no assigned value for that product as outlined above shall be reimbursed at 90% of provider’s billed charge. ·0232T falls under this category of the contract as it has no assigned value on the OMFS. ·Provider billed $2000 for 0232T·Based on information reviewed, additional reimbursement of code 0232T is warranted

 

Example:

ISSUE IN DISPUTE:

Provider is dissatisfied with reimbursement of codes 99205,96101 and denial of codes 99354 and 99355.

Claims administrator reimbursed$453.30 for code 96101 indicating on the Explanation of Review “Workers’ Compensation state fee schedule adjustment”. ·

Provider billed code 96101 x 4.8 units which is rounded up to 5 units as this code is per hour. OMFS shows 96101 allowable $90.66x 5 = 453.30. Provider was reimbursed 100% of OMFS and therefore no further reimbursement is warranted.

Billed code 99205 was down coded to 99204 indicating on the Explanation of Review “Based on the available information, the services rendered appearto best be described by this code/labor code 5307.1”.

99205 -Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:A comprehensive history;A comprehensive examination;Medical decision making of high complexity.

 

Report submitted documents all three components required for a 99205 and therefore, additional reimbursement is warranted for code 99205.

Provider documents on the report a total of 2 hours and 30 minutes spent face to face with the patient. 99205 is considered the first 60 minutes, 99354 is an additional hour with 99355 each additional 30 minutes all of which were submitted on the CMA 1500

 

To see all 101 billing errors and more visit:

 

www.workcompliens.com 

 

Pasted from <https://www.linkedin.com/pulse/wc-101-billing-errors-more-causing-disputes-richard-boggan-jd?trk=mp-reader-card>

 

 

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Lien Activation Fee Back, Court Finds Constitutional and No Injunction

Monday, June 29, 2015

8:21 PM

In summary the issue wasn't whether the law was fair or not,  but whether under the Constitution, did the State have the power to enact the law, and under which standard of review. As the court found no due process rights were violated (procedural and or substantive), no equal protection rights violated  nor was there an unreasonable  taking of property. But that the labor code was rationally  related ( the standard of review) to a legitimate (economic) State interest, i.e. back log of liens. In addition,  the Court held the lower Court Judge erred in issuing an injunction as there was no serious due process rights at stake, as is the standard for issuing the injunction

 

"The panel held that the district court properly dismissed the Takings Clause claim because the economic impact of SB863 and its interference with plaintiffs’ expectations was not sufficiently severe to constitutes taking. The panel further concluded that the lien activation fee did not burden any substantive due process right to court access and also rejected plaintiffs’ claim that the retroactive nature of the lien activation fee violated the Due Process Clause. Vacating the district court’s preliminary injunction, the panel held that the district court abused its indiscretion that a“serious question” existed as to the merits of plaintiffs’ Equal Protection claim. Applying rational basis review, the panel held that Labor Code §4903.06(b), which exempts certain entities other than plaintiffs from having to pay the lien activation fee, was rationally related to the goal of clearing the lien backlog. The panel also reversed the district court’s denial of defendants’ motion to dismiss the Equal Protection Clause claim because the panel’s ruling on the preliminary injunction necessarily resolved the motion to dismiss. "

 

 

Below was taken from the actual decision:

 

"The panel affirmed the district court’s dismissal of plaintiffs’ claims under the Takings Clause and Due Process Clause challenging California Senate Bill 863, vacated the district court’s preliminary injunction and through pendent appellate jurisdiction, reversed the district court’s denial of defendants’ motion to dismiss plaintiffs’ Equal Protection Clause claim.In 2012,"

 

"Conclusion The district court properly dismissed plaintiff Due Process claims. We likewise conclude dismissal without leave to amend is proper because “it is clear, upon denovo review, that the [claims]could not be saved by. . .amendment.” Steckman v. Hart Brewing, Inc., 143 F.3d1293, 1296 (9th Cir. 1998). However, because the district court abused its discretion in concluding that “serious questions” exist as to the merits of plaintiffs’ Equal Protection claim, we vacate the preliminary injunction. Wealso reverse the district court’s denial of defendants’ motion to dismiss the Equal Protection claim because our ruling on the preliminary injunction necessarily resolves the motion to dismiss.

 

AFFIRMED in part, VACATED in part, and Reversed in part  Costs are awarded to defendants"

 

http://cdn.ca9.uscourts.gov/datastore/opinions/2015/06/29/13-56996.pdf

 

 or at www.workcompliens.com

 

In short, what it means is that all liens filed prior to 2013 still on the books and no lien fee paid would be subject to a lien activation fee of $100.00, if a $150.00 was already paid, then the $100.00 would not be required,  it is an either or, not both. The WCAB and the  DWC will give notice on, when , if and how they will start enforcing, giving all parties sufficient notice before any action

 

The upside to the decision is, that most pre-2013 liens filed have already gone through the system and escaped the $100.00 lien activation fee. The  DWC and WCAB will not go back and try to collect those that would have been subject  to a lien activation fee had an injunction not been issued,  disturbing final resolution of those  lien cases.

However, the more negative aspect of the decision is that, although the lien filing fee of $150.00 for liens filed on or after January 01, 2013 was not the subject of this case , it would have naturally followed, had this case resulted in a different finding.

 

As to the automatic dismissal of all liens that did not show a lien  fee paid by January 01, 2014, that did not take place because of the initial injunction, these cases / liens will not be dismissed by law or reapplication of the law that was prevented enforcement by injunction, as the DWC and WCAB will give a new cut off date, if they decide to enforce and or create such a default. As one has to recall, because of the initial injunction, they were prohibited from collecting such a fee, therefore a default cannot now take place without reasonable notice of that default and an opportunity for parties to cure before a default and or dismissal takes place.

 

 As to a possible appeal of the decision, the Plaintiffs have a lot to consider, as they were hit with the defense  costs of the litigation, which is not a small amount, so the possibility  of an appeal,  and considering additional costs and , weighing the chances of success, a decision to appeal by the Plaintiffs  is not a given.

 

 The real issue is how this will affect lien settlements, as some lien claimants have adjusted to the lien fee of $150.00 not the subject of the case and getting settlements by defense attorneys  even when issues should not be be lien filing issues (IBR, IMR).   Thus creating  a take off of what we had prior to 2013, filing liens to get better settlements, regardless of the merits of the case.

 

Therefore, if nothing changes with  the defense settling when a lien is filed, little will change. However, if the DWC requires all liens filed prior to 2013, that do not have a lien fee, to have lien fee (activation) or be dismissed by a given date, then a tremendous issue is present and mass defaults may  take place

 

Note: Thanks to " Workcomp Zone", who first posted the decision yesterday. and Tricia Ruggles who sent out the notice of the case decision.

 

 

Pasted from <https://www.linkedin.com/pulse/lien-activation-fee-back-court-finds-constitutional-richard-boggan-jd>

 

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Simple Consultation (E&M)0 Paid Order 60 Days $805.32 no Lien Plus P&I

Wednesday, July 1, 2015

11:41 AM

 

 

Machine generated alternative text: DETERMINATION OF ISSUE IN DISPUTE: Reimbursement of codes 99205-25, 99354 &
96101-59 is recommended
Workers’ I
Comp ,
Notes
Allowed
DISPUTED SERVICE: Allow
__________ _________ _________ _________ _________ _________ _________ I reimbursement $237.67
DISPUTED SERVICE: Allow
reimbursement $114.35
DISPUTED SERVICE: Allow
reimbursement $453.30
Date of Service: 8.20.2014
Physician Services
Service
Code
Provider
Billed
99205
Plan Dispute
Allowed Amount
$275.00
$0.00
Units Multiple
Surgery
$275.00
1
96101-59
Amt.
N/A
99354
$125.00
$0.00
$125.00
1
N’A
$114.35
$500.00
$237.67
$0.00
$500.00
5
N’A
$453.30

 

Service Code

Provider Billed

Plan Allowed

Dispute  Amount

Units

Multiple Surgery

Workers Comp Allowed

Notes

99205

$275.00

$0.00

$275.00

1

 

$237.67

Award: $237.67

99354

$125.00

$0.00

$125.00

1

 

$114.35

Award: $114.35

96101

$500.00

$0.00

$500.00

5

 

$453.30

Award: 453.30

 

 

 

 

 

 

 

 

 

 

ANALYSIS AND FINDING Based on review of the case file the following is noted:

·ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes 99205-25, 99354 & 96101-59

 

Claims Administrator denied codes indicating on the Explanation of Review “We cannot review this service without necessary documentation. Please resubmit with indicated documentation as soon as possible”

 

Provider states on the IBR application “A copy of the report was attached to the SBR which we sent on January 20, 2015 and again, bill review has denied it with the same explanation as the original denial about needing documentation”

 

Provider’s report submitted titled “Psychological Consultation” states the injured worker was seen for an intake and assessment taking 1.0 hour with prolonged face to face taking an additional 45 minutes.

 

Psychological testing was administered under constant supervision. The total administration time took 3.0 hours, and the scoring and interpretation took 2.0 hours. ·

 

CPT 96101 -Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

 

. Provider documents all tests administered along with scoring and results in the report submitted.

 

A total of 5.0 hours for psychological testing.

·

Based on information reviewed, reimbursement is warranted for codes 99205-25, 99354 & 96101-59

 

Pasted from <http://www.dir.ca.gov/dwc/IBR/IBR-Decisions/Decisions2015/IBR2015_301-600/CB15-0000343.pdf>

 

 

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WC: Liens W/O Activation Fee Will Not Be Dismissed W/O Notice From DWC

Thursday, July 2, 2015

7:15 AM

Regardless, of the injunction being vacated in  Angelotti Chiropractic, Inc., et al. v. Baker, et al.,  that prior acted to prevent the DWC from enforcing the lien activation fee, it will not be reinstated for Lien Claimants until the DWC posts a notice.

 

A lot of speculation  and anticipation as to what will happen in the near future, based on the recent decision that found the lien activation fee of a $100.00 constitutional and thereby set aside the injunction. Some have stated, that after the appeal time process for the decision has expired, and the decision is final, that it will be a free-for-all for the defense to get dismissals of liens, this is incorrect. 

On November 15, 2013, the DWC / DIR issued a bulletin, (which is law) as to its' policy, stating  that it would no longer require and or collect a lien activation based on that injunction. Therefore, that  law and policy in this "Newsline", is the law as written, until the DWC states it will start collecting and or requiring a lien activate fee.

 

First, the Newline of November 15, 2013  , as of today, stands until changed, second our DWC is not that childish to take advantage of a valid challenge and seek revenge on Lien Claimants for challenging the statute. Lastly, due process  and just common sense of fairness mandates sufficient notice, so Lien Claimants can adjust.

 

"Lien claimants whose liens were subject to the activation fee requirement will not be required to pay the $100 fee in order to appear at a hearing or file a Declaration of Readiness to Proceed (DOR) regarding a lien": From DWC / DIR November 2013

 

Even the DWC knows, that there exists good and bad for all parties and now more than ever it is coming into light ( not a pretty sight to see). Therefore, the DWC will not penalize  good providers who relied on the above bulletin, by causing them to fall into massive defaults and or expenses  of millions of dollars without proper notice of its intent, as both valid claims exist and some not so.

 

For the common sense challenged out there, the law that was in effect, that stated all liens not showing a lien fee by January 2014 would be dismissed by operation of law, that did not take place because of the injunction, it is not even a consideration at this point.  As the recent decision does not create a time machine, as if the injunction never existed, as  January 01, 2014 came and went and everyone complied with the law then in effect at that time.   We  all obeyed the law, including the DWC  and relied on that injunction,  which was the law at the time. Therefore, to believe that there is even a remote possibility  that all liens not showing a lien fee are dismissed by operation of law because they failed to pay lien activation fee  by January 01, 2014 , well, I just do not have the words for that kind of thought process, in writing anyway

 

'In short, you cannot create a forfeiture for those who complied with a law, during a time period,  when it was later determined the law was not valid , for those who acted on reliance of that law. Even if it is just an injunction to stop the enforcement of a law,  as it acted to stop compliance with and  was relied on by all parties (DWC January  2013 Directive) . Therefore, it cannot be said they voluntarily did not comply to  justify a forfeiture i.e. dismissal of liens for failure to pay an activation fee of January 01, 2014.

 

 

In work comp today, we are seeing that some insurance companies and defense attorneys are unfairly  taking advantage of SB 863, while others are great. Just like we have bad and good providers, who have taken advantage, but  most are just trying to get it right, those are the ones we cannot forget about, nor can we throw them to the lions.

 

Therefore, to believe the absurd, that the DWC will be a part of a childish tactic is insane, i.e.   that all liens without a lien activation fee will be dismissed after the appeal time has  expired without proper notice from the DWC.  If such action was to take place, it would even have the Appeal Courts  who  decided against the injunction shaking their head in disbelief, and  lawsuits would be  filed in mass by lien claimants,  no, it will not happen that way.

 

Now at the WCAB, some may try the idiotic argument that since the injunction is no longer, then the above newsline / law / policy  is invalid, wrong. Regardless of the underline reason that motivated the DWC policy,  the DWC stated they will not require a lien activation fee, and that remains law until they send notice out that it has changed, regardless of the underline reason for the policy of not requiring the  lien activation fee.

 

 The DWC, DIR, nor the WCAB will not allow or encourage  chaos,  that would be exactly the result if the unthinkable happens and the DWC does not send out notice of intent to enforce and  a sufficient time and opportunity for providers to adjust to the new ruling.

 

The DWC, DIR and WCAB, has always been more than fair in their notice of a change  of enforcement of a law, both, new and old. There would be no reason for them to change that now, it would be out of character for them to do anything but to ensure  sufficient notice and time to adjust in this fact circumstance.

 

The decision discussed above just stated it was Constitutional to require a lien activation fee, it did not order the enforcement of it. When the time to appeal has expired and a final order is had, then the DWC /DIR has to indicate their intent to enforce a law that prior, they stated would not be enforced, a step process if you will.

 

Not to worry,  there will be plenty of time to panic, but the DWC, DIR, and WCAB will not let the process be unorganized, nor absent sufficient time and notice for payment of the lien activation fees, before dismissals start taking place.

 

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WC DOS 2015 Recent Posted IBR Decisions - Fee Schedule Issues Resolved

Friday, July 17, 2015

8:22 PM

WC007-30 & 99354 O  Pay 0 Allowed

 

97799-86 Paid $4,398.76      //    $5,175.00 Allowed

 

97799-86  Paid $5,163.75    ///   allowed  $5,771.25

 

97799-86   Paid $4,590.00   //  $5,130.00

 

G0431 Paid   $20.24   Allowed$107.14

 

95937    Paid $0.00      Allowed   $195.06

 

96101 and 99354   Paid $0.00     Allowed $0.00

 

82486    Paid $59.00     Allowed  $119.94

 

82486   Paid  $59.00    Allowed  $119.94

 

J3490  Paid $    0.00                 Allowed $10,060.87

KD NDC 38779196806; J3490

-KD NDC 38779196806; J1170

-KD NDC 38779073105; J0735

KD NDC 38779056104; J3490

-KD NDC 38779052409

J3490-  Paid 0.00  Allowed    $10,071.37

 

KD NDC 38779196806; J3490 0,071.37

- KD NDC 38779196806; J1170

KD NDC 38779073105; J0735

-KD NDC 38779056104; J3490

-KD NDC 38779052409

 

99215     Paid   $0.00 / $0.00    allowed  $84.99 / $77.70

- 25 and 62370

 

ML104-94 (down coded to ML102) Paid  $625.00   Allowed $625.00

 

WC007-30   Paid  0.00     Allowed $141.91

 

95937   Paid   $0.00     Allowed  $195.06

 

63685    Paid  $5,795.02           Allowed  $26,913.61

 

99214 and WC002   Paid   $0.00    Allowed  $125.14 / $11.91

 

WC004 Paid  $0.00  Allowed  $166.96

 

95937   Paid  $0.00  Allowed  $195.06

 

11012  Paid  $0.00   Allowed $262.09

 

99203-25   Paid $0.00     Allowed $106.58

 

J3490                            PAID               $0.00    Allowed $ 6,144.70

KD (3877919680

6  ); J1170-KD (38779073105); J0735-KD

(38779056104)

 

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Urine Drug Screening Why Billing 82486 is Not Correct, What Is Correct

Saturday, July 18, 2015

6:20 AM

Billing for urine dug screening in California  has a unique story, apart from other States that use Medicare as a bases for their fee schedule, in regards to these services.

 

Before we get into billing urine drug screen in general, let's address 82486 immediately and be done with it.

CPT 82486: Chromatography, qualitative; column (e.g., gas liquid or HPLC), analyte not elsewhere specified

There existed a time, a period of time when  this billing code 82486 would spit out a reimbursement for  approximately  $1,300.00. As such, like finding a combination to a safe, the coding became popular, and still used today in large numbers.

 

However, 82486 was to be used, if  the tests were not described  elsewhere  ( "analyte not elsewhere specified")

Based on the tests performed, a  comparable billing code describer for 82486,  was  G0431, (Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) used to report more complex testing methods, such as multi-channel chemistry analyzers, where a more complex instrumented device is required to perform some or all of the screening tests for the patient.

For the majority of those billing 82486, in the last 3 years or more, the code was changed to G0431 and paid at $119.94 or less in payments from insurance companies and steadfast in IBR decisions, except for a few  insurance companies.

 

Over the past 3 years, a wide verity of billing codes for urine drug screening have been attempted, from chemistry coding to numerous 80000s coding. To the IBR (Independent Bill Review) process, these codes  held little impact, as all were bundled under G0431 and paid at $119.00 or less.  In fact,  recent  IBR decisions  have held 0 payment for 82486, stating coding is not justified by authorization or reports do not reflect the need for 82486.

Now other States, using Medicare Payments Guidelines, would not bundle all 80000 codes under G0431, except for the original two codes that G031 actually replaced.

 

Then in 2014, Medicare posted new G codes for 2015 and stated that they could  not be used because they were not ready, they also stated that they were aware that the present coding system was lacking, but because of the potential  for abuse they were holding off adopting the 2015 proposed coding

 

  The new CPT codes are divided into 3 classifications: Therapeutic Drug Assay, Drug Assay and Chemistry. The Drug Assay codes are further differentiated into two categories. The Presumptive Drug Class codes are used to identify possible use or non-use of a drug. The Definitive Drug Class describes qualitative or quantitative tests to identify possible use or non-use of a drug. The Definitive Drug Class codes describe specific drugs and their associated metabolite(s).

 

The Presumptive Drug Class Screening codes (80300-80304) are based on a List of Drugs that is included in CPT. Definitive Drug Testing codes (80320-80377) and common analytes are noted in a separate table in CPT for easy identification. The Therapeutic Drug Assays (80150-80299) are used to monitor clinical response to a known prescribed medication. These codes are specific to the medication.

 

In Medicares' published paper, they put forth crosswalk coding to be used in 2014 and 2015,  listing  the new G codes, also indicating what coding had a separate reimbursement for tests performed and which codes  or tests were bundled still under G0431 and G0434. Which are actually fewer that what California is bundling and more in line with other States regarding what is bundled and what is not.

 

In California, something new took place in the last three years, as opposed to prior to SB 863,  that being billing codes no longer operated as a roulette wheel, meaning, you landed on the right number you got paid.

 

Now,  insurance companies and the States' contracted bill review service (IBR), are matching  billing codes with medical reports with what was authorized before payments are issued, yes a few of insurance companies have not caught up , but for the majority, this is the way it is today. In fact, the substantial monies reduced by billing is not as some perceived, i.e.  based on the new RBRVS,  but are in fact based on medicals and  authorization  not supporting the codes used,also a lot of no modifiers or incorrect modifiers.

 

Therefore, yes, in some circumstances based on tests performed, based on the authorization, based on the medical necessity and based on knowing what codes are bundled and which ones not, cases do exist that warrant above the $119.95 and not just because of errors by a few insurance companies.

 

The sad part of the story of 82486, for some, is that when a few spun the roulette wheel and land on 82486, most started playing the same number without thought. While  bundling under G0431 should have been the issue, along with medical necessity,   drugs tested and the nature of injury and or treatment that the drugs  were tested for.

 

In fact to take it a step further, in California, accepting the exceptional  payments as 1 out of a 100 as acceptable, instead of mandating it as the norm, if done correctly, is common place for Providers  2015. This accounts for why we are not seeing changes in the IMR decisions and why still, three years in,  the IBR process is not  widely used,  and  the wide spread use of generic medical reports  that accounts for noticeable  UR denials and 0 payments.

by: www.workcompliens.com

 

 

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Liens Time Limits / Fees, Few Exceptions and Laws Not Used or Explored

Saturday, July 18, 2015

9:56 AM

The purpose of filing liens, does not have the intent that the creators of SB 863 hoped for. The design of SB 863 and the 2012 En Banc Torres case, was to have the effect, that Providers would take cases and or disputes more seriously, i.e. only viable possible winnable cases would need liens.  In fact, that is why the lien fee and or lien activation fee was made, to create a process where liens without merit would not be filed using  the filing fee as a deterrent.

 

 

However, since the start of 2013,  this so called deterrent lasted less than 8 months, i.e. great number of sanctions from that time for unprepared  cases for lien claimants. Then some just fell back into the old ways, filing liens and getting settlements regardless of the development  of these dispute files. The cause of this is by no small part of insurance companies  who refuse to settle or even consider settling without a lien filed.

 

Therefore, even though the laws as written, were not to encourage liens but to dissuade and use the other two dispute forums,  IBRs and IMRS  to issue orders, that were prior issued by the WCAB, the system mandates liens, in fact even more than prior.

 

The question then has to be asked, is the DWC turning a blind eye to the abuse that is causing liens to be filed because of the revenue that lien fees produce, or are they just in the dark why liens are essential, now 3 years into SB 863.

There were and are laws specifically created under SB 863, that would take away the need for liens, not in the enforcement by defaults, but through the positive reinforcement of getting paid fee schedule.  There is also case law that needs further exploration as to its' limits of interpretation, both for dates of services, prior to 2013 and those post 2013.

There are actually a total of 14 laws, that allow exceptions to filing liens and or time limits, or when a lien is not required to get am order for full payments, even if the parallel  time limits to file liens has  expired. However  for the purpose of this post we will address only 2 out of 14, as the others are a more complex,  require additional writings and if not understood completely, would not bring about the results that the laws intended, as written.

 

1. Medical Legal Disputes - no lien, no lien fee and no lien time limits:

 

Petition for Determination of Non-IBR Medical-Legal Dispute (WCAB Rule 10451.1(c)(3)). Again, in both of these scenarios, a lien is not required and, if one is not filed, a lien filing fee need not be paid. Furthermore, the dispute is not subject to IBR and, therefore, the IBR fee does not come into play.”

 

FINAL STATEMENT OF REASONS Subject Matter of Proposed Regulations: FINAL RULES OF PRACTICE AND PROCEDURE (Cal. Code Regs., title 8, §§ 10210 et seq. & 10300 et seq.) Effective - Oct. 23, 2013 page 7, “6.Section Added: 10451.3 a)If the medical-legal dispute is over an issue other than the amount payable under an official fee schedule in effect on the date the interpreter’s services were provided, and if the interpreter has both timely requested second review (Lab. Code, § 4622(b)(1)) and timely objected to the defendant’s final written determination after second review (Lab. Code, § 4622(c)), then the defendant is obligated to file a DOR and a Petition for Determination of Non-IBR Medical-Legal Dispute (Lab. Code, § 4622(c); WCAB Rule 10451.1(c)(2).) Moreover, if the defendant breaches any of its duties under section 4622 relating to a non-IBR medical-legal dispute, then the interpreter may file a DOR and a Petition for Determination of Non-IBR Medical-Legal Dispute (WCAB Rule 10451.1(c)(3)). Again, in both of these scenarios, a lien is not required and, if one is not filed, a lien filing fee need not be paid. Furthermore, the dispute is not subject to IBR and, therefore, the IBR fee does not come into play.”

 

2. The below, no lien is  required, no lien fee, no time limits,  if no UR because of contested liability issues, and that issue is resolved, i.e. expiated hearing, case in chief etc. it is required to go through UR then IMR and IBR if necessary, no lien and is enforced by petition,  without liens.

 

§9792.9.1 (b) (2) If utilization review is deferred pursuant to this subdivision, and it is finally determined that the claims administrator is liable for treatment of the condition for which treatment is recommended, either by decision of the Workers’ Compensation Appeals Board or by agreement between the parties, the time for the claims administrator to conduct retrospective utilization review in accordance with this section shall begin on the date the determination of the claims administrator’s liability becomes final. The time for the claims administrator to conduct prospective utilization review shall commence from the date of the claims administrator’s receipt of a DWC Form RFA after the final determination of liability.

by: www.workcompliens.com

 

 

 

The below has more application than what most are using it for --- it is not only mean the end of dates of services that you provide. One example out of several is that of copy services, does the time mean lack of continual services, or is it because discovery is open until the case is resolved, that is the last date of services, same as is the same with interpreters. i,e, last date of services when interpreter services no longer needed (i,r, case over) ? -- one needs to understand the intent of the law and the decision.

 

Or can we use the treatment guidelines to define what is continual  medical treatment, i.e., drug testing, therapy, medications, etc, in which the guidelines, for example state testing warranted for low risk twice a year so last date of service would be when drug testing no longer necessary, or until 24 therapy completed even if break in treatment or when post therapy is exhausted,  as the guidelines state that is what is required / recommended?

 

Getting liens filed post or prior DOS to 2013, getting lien fees back, is not the issue, that is simple. The issue is, that Providers in a large portion of the time do not get paid what they should when filing liens, as compared to using other remedies available under SB 863, this is where Providers are just throwing away monies rightfully due them.

 

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For Defense & Providers 72 Petitions Prior to Lien & After, Most Unused

 

 

Sunday, July 19, 2015

7:40 AM

 

By www.workcompliens.com

 

In every regulation adopted under SB 863, whether it be IBR, IMR or medical-legal or any number  of several procedures or  laws enacted since 2012, it  is stated, that a party is subject to sanctions, dismissal or payments,  if  either party fails to  follow what was stated in that regulation.

 

In addition to sanctions, dismissals and payments by petition, we have additional petitions both for the Defense and or Providers that resolves issues without liens and or compels the other party to comply with the laws as written, including failure to  negotiated in good faith. 

 

For the Defense, we are seeing the introduction of several petitions that existed for  years but hardly ever used.  For providers we have a series of petitions unknown and hardly ever used.

 

For Defense

 

We are seeing Petitions for Dismissal of Liens for filing a lien on issues that were subject to the IBR or IMR process.

 

When filing a lien, the party filing a lien has to sign a declaration under penalty of perjury that the issue for which a lien is filed, is not subject to the IMR or IBR process and if such a lien is filed the party is  subject to dismissal and sanctions, by Petition.

 

§10770.5 (a) (2) (b) The verification under penalty of perjury shall also contain a statement declaring that the lien is not being filed solely because of a dispute subject to the independent medical review and/or the independent bill review process.

 

Note: only an untimely second review or an  untimely UR is outside the IMR or IBR process. other issues attached such as contested liability issues to payments and medical necessity are lien cases, Also defective URs are not WCAB issues but IMR issues, therefore subject to sanctions and dismissal if lien is filed.

 

§ 9792.5.5 (e) If the only dispute is the amount of payment and the provider does not request a second review within the timeframes set forth in subdivision (b), the bill shall be deemed satisfied and neither the claims administrator nor the employee shall be liable for any further payment.

 

Note: if one is contesting lack of medical reports or UR reviewer was not proper i.e., expertise of the reviewing physician and compliance with the MTUS, fling a lien on these issues subjects the party to sanctions and dismissal 

 

A UR decision is invalid and not subject to independent medical review (IMR) only if it is untimely;

 

With the exception of timeliness, all other requirements go to the validity of the medical decision or decision-making process. The sufficiency of the medical records provided, expertise of the reviewing physician and compliance with the MTUS are all questions for the medical professional .If an injured worker disputes a UR decision, section 4610 mandates that that it “shall be resolved in accordance with Section 4610.5, if applicable ... .” En Banc Jose Dubon v. World Restoration, Inc.; and State Compensation Insurance Fund Oct. 6, 2014

Case No: ADJ4274323 (ANA 0387677) - ADJ1601669 (ANA 0388466)79 Cal. Comp. Cases 1298

 

With the exception of timeliness, all other requirements go to the validity of the medical decision or decision-making process. The sufficiency of the medical records provided, expertise of the reviewing physician and compliance with the MTUS are all questions for the medical professional. If an injured worker disputes a UR decision, section 4610 mandates that it “shall be resolved in accordance with Section 4610.5, if applicable ... .” (§ 4610(g)(3)(A) (italics added); see also § 4610(g)(3)(B).) Similarly, sections 4610.5 and 4610.6, more thoroughly discussed above, specifically provide that where there is a dispute regarding a UR decision on “medical necessity,”the dispute shall be resolved only by IMR. (§ 4610.5(a)(1) & (2), (b), (e), (k).) With the exception of timeliness, all defects in the UR process can be remedied when appealed to IMR En Banc Jose Dubon v. World Restoration, Inc.; and State Compensation Insurance Fund Oct. 6, 2014

Case No: ADJ4274323 (ANA 0387677) - ADJ1601669 (ANA 0388466)79 Cal. Comp. Cases 1298

 

 In addition, a response to a second bill review request is never untimely,  regardless when responded to, if the initial request for second review was not done on proper form or did not have all the required documents attached, there is no wavier  by defense if they responded to an incorrect request for second review.

 

§ 9792.5.5 (f) A claims administrator may respond to a request for second bill review that does not comply with the requirements of subdivision (d). Any response to such a request is not subject to the requirements of subdivisions (g) and (h) of this section.

 

The reason I emphasized the above, is to point out, that those who still persist in treating on UR denials and filed liens, are potentially  building up massive sanctions and dismissals.

 

The only case published on the above issue is below:

 

Recent case allowed dismissal and sanctions for an exempt hospital who asserted that its outpatient services were exempt from the fee schedule and filed a lien, The defense filed for sanctions and dismissal, court held that although inpatient services were exempt, outpatient services were subject to fee schedule and subject to the IBR process therefore dismissal and sanctions  warranted.

 

Provider states they are “Long Term Care Hospital”. Provider billed services for date of service 02/28/2014 on an outpatient basis. Provider’s operative note dated February 28, 2014 states “Plan: He will be discharged today, followed up in 10 days, and start therapy in four weeks.” Claims Administrator reimbursed $6125.36 and indicated “Provider is billing their services as outpatient services in which the outpatient ruling does not list long term care hospitals as being exempt from the fee schedule. They are exempt from IPPS, but not OPPS in which case the OPPS rules would still apply to this bill. Additionally, the provider is within the PPO network and subject to further reductions.

 

Next we have the:§10582.5. Dismissal of Inactive Lien Claims for Lack of Prosecution.

 

The following  was put forth as the purpose for 10582.5 that became effective at the end of  2012 and applied to all dates of services regardless of when a lien was filed.

 

  • The provisions of proposed new Rule 10582.5 will not become operative until January 1, 2012, thereby giving lien claimants a reasonable time to file a DOR before their lien claims would be subject to potential dismissal for lack of prosecution. (See Rosefield Packing Co. v. Superior Court(1935) 4 Cal.2d 120, 122

 

Pasted from <https://www.dir.ca.gov/wcab/WCABProposedRegulations/WCAB_July2011/ISOR.pdf>

 

  • The proposed procedure of Rule 10582.5 will cause lien claimants to pursue their lien claims in a timely manner, before evidence is lost and witnesses disappear or have their memories dimmed.

 

  • This will result in a reduction of the number of hearings needed to address discovery issues in lien cases. Such hearings arise more frequently when evidence is no longer available or difficult to resurrect.

 

  • Also, the proposed procedure will create more certainty and predictability in workers’ compensation claims management by allowing insurance carriers and self-insured employers to close their cases, liquidate their reserves, and more accurately predict future liabilities.

 

  • Further, the proposed procedure will allow a dormant lien claim to be dismissed through pleadings, without a hearing, if a lien claimant does not timely object to the dismissal after having notice and an opportunity to be heard. Therefore, calendar time that otherwise would be used can be devoted to hearings resolving disputes between injured employees and their employers or insurance carriers over the employees’ rights to benefits

 

10582.5 actually  means, that once the petition is filed,  a dismissal of the lien is a given, if a DOR was not filed within 180 days of the Case in Chief Resolving, no do over, no excuses, plain in simple.The reason for the above is because of what is called a "letter of intent to file", as before the actual petition is filed, a letter of intent by the defense must be sent. With most Providers not recognizing what that letter means, lack of action causes the petition to be filed  and then the dismissal for failure to take action from  the letter of intent, makes a dismissal just a a matter of procedure, i.e., it (letter) is not done on pleading, so attention that it warrants is not given.

 

§10582.5 (b) At least 30 days prior to filing a petition to dismiss a lien claim for lack of prosecution, the petitioner shall send a letter to the lien claimant and, if represented, to the lien claimant's attorney or representative of record, stating petitioner's intention to file such a petition.

 

§10582.5 (j) This section shall become operative on August 1, 2012 and, except as provided in subdivision (k), shall apply to all lien claims, regardless of the date of filing of the lien claim, the injured employee's date(s) of injury, or the date(s) on which the lien claimant provided the service(s) that are the subject of the lien claim.

 

10582.5. Dismissal of Inactive Lien Claims for Lack of Prosecution.

 

(a) A lien claim may be dismissed for lack of prosecution on a petition filed by a party or on the Workers' Compensation Appeals Board's own motion if the lien claimant fails to file a declaration of readiness to proceed by the earlier of:

 

(1) 180 days after the lien claimant becomes a “party” within the meaning of section 10301(dd)(6); or

 

(2) 180 days after a lien conference or lien trial at which the lien claim was at issue is ordered off calendar.

The 180-day period of subdivision (a)(1) is computed from the date that the original owner of the lien claim became a party or would have become a party if it still owned the lien claim.

 

(b) At least 30 days prior to filing a petition to dismiss a lien claim for lack of prosecution, the petitioner shall send a letter to the lien claimant and, if represented, to the lien claimant's attorney or representative of record, stating petitioner's intention to file such a petition.

 

(c) A petition to dismiss a lien claim for lack of prosecution shall be accompanied by all of the following:

 

 (1) A copy of the 30-day letter referenced in subdivision (b).

 

 (2) A declaration under penalty of perjury stating whether:

 

 (A) the lien claimant has served the petitioner with a declaration of readiness and, if so, the date of such service.

 

 (B) the petitioner has received any billing(s) from the lien claimant and, if so, stating either:

 

 (i) the petitioner made a reasonable and good faith payment and, where required, an explanation of review on each billing consistent with all applicable law(s); or

 

 (ii) the reason(s) why no such payment or tender of payment was made.

 

 (C) the petitioner has timely served all medical reports and medical-legal reports on the lien claimant, to the extent provided by section 10608.

 

 (d) In addition to the requirements of subdivision (c), a petition to dismiss a lien claim for lack of prosecution shall be accompanied by the following, as applicable:

 

 (1) If the petition seeks dismissal under section 10582.5(a)(1) based on the lien claimant's failure to file a declaration of readiness to proceed within 180 days after the underlying case has resolved within the meaning of section 10301(dd)(6)(A), the petition shall be accompanied by: 

 

(A) a copy of an order approving a compromise and release agreement, a stipulated Findings and Award, an adjudicated Findings and Award, or any other decision or order resolving the underlying case; and

 

 (B) if this decision or order was served by designated service under section 10500(a), proof that it was served on the lien claimant.

 

 (2) If the petition seeks dismissal under section 10582.5(a)(1) based on the lien claimant's failure to file a declaration of readiness to proceed within 180 days after the injured employee or the dependent(s) of a deceased employee “choose(s) not to proceed with his, her, or their case” within the meaning of section 10301(dd) (6)(B), the petition shall be accompanied by a declaration concisely stating facts to support the “choose(s) not to proceed” allegation. This declaration, at a minimum, shall specify based on the petitioner's knowledge and belief:

 

 (A) the nature and date of the last activity by the injured employee or the dependent(s) of a deceased employee relating to the case; and

 

 (B) the nature and date of the last payment of disability indemnity.

 

 (3) If the petition seeks dismissal under section 10582.5(a)(2), the petition shall be accompanied by a copy of the order taking the lien conference or lien trial at which the lien claim was at issue off calendar.

 

 (e) A copy of the petition to dismiss a lien claim for lack of prosecution shall be served on each of the following, together with a proof of service:

 

(1) the lien claimant and, if represented, the lien claimant's attorney or representative of record;

 

(2) any defendant(s) in any case(s) listed on the lien claim or, if represented, the attorney or representative of record of any such defendant(s); and

 

(3) the injured employee and, if represented, the injured employee's attorney or representative of record.

 

(f) A lien claim shall not be dismissed for lack of prosecution unless:

 

(1) the Workers' Compensation Appeals Board has issued a notice of intention to dismiss with or without prejudice,

giving the lien claimant at least 30 days to file written objection showing good cause to the contrary; and

 

(2) the lien claimant fails to timely object or the written objection, on its face, fails to show good cause.

Any objection to the notice of intention shall be filed with the Workers' Compensation Appeals Board and served on the defendant(s).

 

(g) If a defendant is designated to serve the notice of intention to dismiss under section 10500(a), the defendant shall serve the notice of intention within 10 business days. If the defendant does not receive a timely objection (taking into consideration the time extension provisions of sections 10507 and 10508), the defendant shall file and serve a proposed order dismissing the lien and copies of the notice of intention and the notice's proof of service.

 

(h) An order dismissing a lien claim for lack of prosecution shall be served only by the Workers' Compensation Appeals Board and not by designated service.

 

(i) All pleadings and declarations filed under this section shall be verified under penalty of perjury in the manner required for verified pleadings in courts of record.

 

(j) This section shall become operative on August 1, 2012 and, except as provided in subdivision (k), shall apply to all lien claims, regardless of the date of filing of the lien claim, the injured employee's date(s) of injury, or the date(s) on which the lien claimant provided the service(s) that are the subject of the lien claim.

 

(k) This section shall not apply to the lien claim(s) of any of the following: (1) the Employment Development Department; (2) the California Victims of Crime Program; (3) any lien claimant listed as being excepted under parts (A) through (C) of section 10205.10(c)(5); and (4) any governmental entity pursuing a lien claim for child support or spousal support; and (5) the Uninsured Employers Benefits Trust Fund.

 

For Providers:

 

For Providers, under  the regulations adopted under SB 863, there are several, in fact Petitions both prior to a lien and or  after a lien is filed that few  use, including petition for payments However, because  Petitions were not widely used by providers prior to 2013,  the availability of them under SB 863 have most not using them, but they exist.

One  of  most valuable petitions   for providers and  not used is the "Petition for Non-IBR Medical Legal Disputes" , there are many more, but this is the most strange, as to why not used excessively .

 

For Providers, there is a multiple of Petitions that allows payments and determination of medical necessity issues without having liens filed and or subject to the time to file liens, which most have not availed themselves of, regardless whether treatment or medical-legal.

 

Now, the greatest error by both defense and providers in petitions or notice of intent (NOI), is the failure to request an order after a NOI is issued and a response is made or not made. Most Judges will issue an NOI , either for dismissal  and or payments but it is up to the party to request an order after the time of the NOI is expired or a response is made but no good cause is shown, if  such a follow up is not made, most of the time final orders are not issued by a Judge.

 

by www.workcompliens.com

http://www.workcompliens.com/4-Book-2015-Pleadings-WCAB.html

 

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WC: Clarification Of Lien Laws When Applied & Time Limits and When Not

Monday, July 20, 2015

11:15 AM

If a lien has not been filed or if a lien is filed in 2013, or If the date of Service is on or after January 1, 2013 the below applies.

 

Labor Code § 4903.5, subdivision (a) "A lien claim for expenses as provided in subdivision (b) of Section 4903 shall not be filed after three years from the date the services were provided, nor more than 18 months after the date if the services were provided on are after July 1, 2013

 

1. 3 years from last date of services if filed on or after January 01, 2013 (note this is regardless of the date of service or when the case in chief is resolved, if a lien is filed in 2013 this law applies)

 

2. 18 months from the last date of services if the date of service is on or after July 01, 2013

 

 

CHARLES KINDELBERGER, vs. CITY OF LOS ANGELES, permissibly self- AND DECISION Case Nos. May 24, 2013;ADJ586942 (VNO 0384663) ADJ687483 (VNO 0384664) OPINION AND ORDER GRANTING PETITION FOR RECONSIDERATION "In the case of ongoing treatment, "the date the services were provided" is understood to be the last date that treatment was provided. Defendant contends that the changes in the time limits to file a lien under amended section 4903.5(a) also altered the construction of that phrase, so that it now means that the operative date is the individual date of service. But no changes were made to that phrase when the statute was amended.

 

Moreover, the interpretation urged by defendant would create a separate statute of limitations for each date of treatment rather than for the entire lien. As a result, it is foreseeable that even while continuing to treat an applicant, a careful lien claimant would file a lien for each date of treatment rather than simply filing a lien at the conclusion of the treatment, thereby flooding defendants and the Workers' Compensation Appeals Board with multiple extraneous liens".

 

An issue yet to  put forth in front of the WCAB, is what happens when there is a cross over between dates of services prior to July 01, 2013 and after July 01, 2013 of continues medical treatment. Which date of services acts as an umbrella   or do two sets of liens need to be filed if the 18 months expires before the 3 years, safe rule, file before the 18 months expires.

 

Or a long stretch of continuous medical treatment could be when the injured worker is P&S'd, few, if any Judges would let that by them, but it could be a good faith argument,  if the facts are right and the case mandates the logic put forth in the above case law.

 

Yet to be tried, continuous treatment and or services outside treatment, what is considered continuous, i.e. copy services throughout the case, even though, say services are provided only every six months. Or say an interpreter, who interprets,  for the same injured worker for different providers in a case, is that continuous  dates of services when the last provider stops treating or does the interpreter need to file a lien for each provider that the services are provided?

 

Future Medical: Prior to 2013 for an award of future medical treatment Labor Code 5803 controlled , as opposed to Labor Code 4903.5  This issue to date, has not been tried, but the last date of services for future medical appears to be the correct interpretation under SB 863, mandating a lien to be filed.

 

Barbara Ann Hingtgen, Applicant v. County of San Bernardino, PSI, Defendant (2012) W.C.A.B. No. ADJ446534 (SBR 0216831)—writ denied case

“In summary, the Appeals Board's allowance of AMG's medical treatment expenses is a matter of enforcing the Stipulated Award for future medical treatment, which defendant agreed to provide beginning in 1997. Under the circumstances of this case, we conclude that the Board's power to enforce the Stipulated Award is not subject to the constraints of Labor Code section 4903.5(a). Therefore, we will affirm our decision of April 11, 2011"

 

When Liens Not Required, Nor Compliance with Lien Filing Time Lines Required

 

Petition for Costs: Usually by Interpreters  for Court services, depositions

 

Medial-Legal Services, AME, QME, PTP, Testing, Interpreters, Copy Services and referral for medical-legal by PTP (Case law) : under " Petition for Non-IBR Medical Legal Disputes"

 

If UR is deferred because of contested liability issue and Court order resolving or by agreement, then a IMR decision can be had without a lien or time to file. (this is why it is extremely important that treatment within the guidelines, as 18 months to file a lien, a lot will be missed)

 

If a contested  liability issue and issues of medical necessity resolved by court order or agreement, then can get a second review and or IBR without lien and or time to file lien.

 

By consent of the parties, if the claims' adjuster agrees to send it through 2nd review and waive the time limits maybe IBR qualified. To get consent by the claims administration you have to be a decent Provider, yes claims adjusters do rate Providers.

 

Consent: As orders overturning UR denials, can be had after the time to file liens have expired or IBR decisions and enforced by the Petition for payments. But it is not a nuisance route, it is a route where a Provider is good enough to warrant the respect of an adjuster to allow that Provider to do that, it is not something one can force on an adjuster, except if a court order resolves a contested liability issue as discussed above.

 

Dates of Services Prior to 2013 and Case In Chief Resolved Prior to 2013

 

Prior to 2012 liens, under certain fact circumstances liens were required to be filed by the defense, if they had notice of that lien, when resolving the case in chief-- it was mandatory by law.

 

In 2012, they modified the law stating it only applied if the Provider was objecting within 90 days, although most Judges would not apply it, regardless, it is the law and clearly written.

 

Even though this is still the law today, with the strict requirements set forth in the 2012 changes,  one would have to be very good in applying it, as written, a lot of research and facts have to fit, an extremely hard sell.

 

 The main issue today, regardless of the complexity of laws and what happens in a case or what exception one is trying for, if the treatment is not in accordance with the guidelines or exceptions to the guidelines  noted, reasonable and necessary for the injured, jumping over hurdles means nothing, as opposed to treating within the guidelines, then it means everything.

 

The true issue for Providers, is letting go of the fact that filing liens is not the only route available. In fact, the IMR and especially the IBR process produces better results. Even if one does not want file an IBR because of the fee, use IBR decisions to get paid at second review. All a Provider has to do is treat within the guidelines or if an expectation to guidelines put it in the medicals, denied cases, admitted cases, the IMR and IBR is where a Provider wants to be.   Liens are necessary, but not to the degree Providers are using it today and missing the benefits that is theirs under the IMR and IBR process. Playing the lien game, in the degree it is being played by some today, just no longer makes sense.

 

by: www.workcompliens.com

 

 

http://workcompliens.com/4-Book-liens-2015.html

 

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MPN Non-MPN Provider Sends to Ancillary Service, Does MPN Defense Hold

Thursday, July 23, 2015

5:44 AM

As with any research paper regarding Providers, when addressing the law as to what is allowed and what is not, the end result in is always the  same,  was the treatment and services reasonable and necessary within the treatment guidelines  and or if an exception, so noted in the medicals. 

 

A presumption is the law, that a default by an adjuster  makes treatment  reasonable and necessary, does not exist. It sounds good, but it is a myth, it is always the burden of the Provider to show the treatment was reasonable and necessary, unless the services were expressly authorized. Therefore, when one finds a complication of the law and spends all this time and fees, because they are right, if at the end of that long path, medical necessity within the treatment guidelines  is not documented in the medicals, it is all for nothing.

 

En Banc Jose Dubon v. World Restoration, Inc.; and State Compensation Insurance Fund Oct. 6, 2014

Case No: ADJ4274323 (ANA 0387677) - ADJ1601669 (ANA 0388466)79 Cal. Comp. Cases 1298"Thus, where a defendant’s UR decision is untimely,the injured employee is nevertheless entitled only to“reasonably required” medical treatment (§ 4600(a)) and it is the employee’s burden to establish his or her entitlement to any particular treatment(§§ 3202.5, 5705), including showing either that the treatment falls within the presumptively correct MTUSor that this presumption has been rebutted. (§ 4604.5; see also § 5307.27.) Moreover, to carry this burden, the employee must present substantial medical evidence. (Braewood Convalescent Hosp. v. Workers’ Comp. Appeals Bd.(Bolton) (1983) 34 Cal.3d 159, 164 [48 Cal.Comp.Cases 566]; Hegglin v. Workmen’s Comp. Appeals Bd.(1971) 4 Cal.3d 162, 169-170 [36 Cal.Comp.Cases 93].)

 

Now onto MPNs, so this Provider asks me about a few issues they are facing, and one of them was an MPN issue, in which the defense being, that  since the referring Provider was not in the MPN, therefore their services, (ancillary services) are considered treatment outside the MPN and no payment.

 

Now the above defense is not exactly true, although for many years, Providers have accepted it to the tune of low or  no settlements, some warranted, some not, but once again, it all comes down to medical necessity.

 

If a Provider treats outside an MPN and the Defense sustains their burden of proof of a valid MPN with proper notice and the Provider cannot prove up that lack of notice resulting in unreasonable offer of medical treatment (again medical necessity), all that means is the adjuster by law, is not obligated to pay that Provider.

 

What a Provider who treats outside an MPN does not mean; is that the services were not reasonable and necessary, it does not mean that its' medicals are excluded, it does not mean referrals to ancillary services were not reasonable and necessary.

 

Outside, referring to a medical specialist  ( physician) in which the same accessibility has to be shown, the referral to an ancillary  provider, if not required by that particular MPN would still be valid, as depending on what ancillary services may not be subject to MPN mandates.

 

In short, the contamination of treating outside the MPN does not follow all referrals if that referral is not subject to the MPN requirements, ( MPN by 2014 law as to allow  ancillary services as part of MPN based on amended  MPN applications approved by the DWC), if that services are  part of the MPN in question

 

Example: A non-MPN provider refers for urine drug testing, the lab is now a provider (in this fact circumstances), it was determined that the injured worker could not treat outside an MPN, which means the Provider does not get paid, that's all.

 

The medical reports of that non-MPN Provider are admissible to show the drug screen was reasonable and necessary, the defense states that the lab was referred by an NON-MPN provider therefore no payments.  But this MPN has no Lab as an ancillary services, so  not subject to MPN, and therefore if reasonable and necessary, MPN defense does no apply.

In short, how can a defense be, that the lab is not payable because outside of the MPN, if the MPN does not provide lab in the MPN and the testing was reasonable and necessary within the guidelines, based on admissible NON-MPN medical reports? -- How can a defense be that the testing should have been in the MPN (if reasonable and necessary) when the MPN does not provide testing Providers as part of their MPN?

 

Remembering that when asserting the above, you need the laws that apply to the above  arguments, without laws, they are just that, arguments. For the above, there are two en banc decisions  and three regulations that make the above a true statement of law, as long as the treatment was reasonable and necessary.

 

 

Like those disclaimers we used to see on TV for dangerous acts "don't try this at home", so to is the above, "Don't try this without the citable law necessary".

 

 

Now, the problem is that some Providers  have been accepting this defense since 2004, but to be fair recent laws substantiate  the above, so just putting forth the arguments without the laws will probably procedure little results, as it been accepted for so long, even though incorrectly.

 

I believe most get the point, knowledge and proof of the laws changes the course of a great many issues, including medical necessity and payments, while the old ways just results in losses, both for the injured worker and the Provider.

 

Case in Point: A provider tells me for inpatient spinal surgery that the insurance is certifying as UR reasonable and necessary-- but will not authorize because hospital not part of MPN. I tell the Provider of the 2009 en Banc Decision Cervantes, that held once spinal surgery is certified as medically necessary they have to authorize it (at time spinal surgery had different rules) or the adjuster has to do a medical legal, millions shifted from insurance company to provider. Now If I tell the Defense that Cervantes was regulated out in 2012, specifically mentioned in the regulations, as no longer law, due to the IMR process, millions shift back to the insurance fromm the Provider. Regardless of type of provider that is the way it works, knowledge or lack of, is a difference maker

 

 

 

 

by: www.workcompliens.com

 

Link below to 2015 book on MPN issues , denied cases and contested liability issues

 

 http://www.workcompliens.com/4-Book-MPN-contested-Liability-2014.html

 

Pasted from <https://www.linkedin.com/pulse/mpn-non-mpn-provider-sends-ancillary-service-does-hold-boggan-jd-6029947908848111616?trk=mp-reader-card>

 

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Connecting Laws Danger of
Templates
Reference Sheet Collection Process
Common Mistakes By Providers
Liens By Operation of Law /
Medical Legal
Liens By Operation of Law /
Medical Legal /2nd
Liens and how they relate to IBR and
IMR
Liens and how they relate to IBR and
IMR / 2nd
Liens and how they relate to IBR and
IMR / 3rd
Treatment and Payments
Unnecessary Disputes
Reasonable Payments Using the IBR
Process
Getting Treatment Authrized
Treatment and Payments
Unnecessary Disputes 2nd
Fee Schedule / Reasonable Reimbursements and Usual And
Customary Based on IBR Decisions and Case Law
Treatment and Payments
Unnecessary Disputes 3rd
Getting Reasonable Payments
Authorization
Collections
2nd Review and IBR Process /
Sanctions
Introduction Overview
Quick Fixes for Immediately  
Payments
MPNs and Contested Liability Issues
IBR and Charts Part 2
EORs and Medical Legal
2015 Recorded Lectures / Work Shops
For Treatment and Collection Disputes  
/ How to Organize Under SB 863  and
Lien Issues
Medical Necessity Issues Based on MTUS, ODG, ACOEM and
Published Medical Journals
Publications
Publications
Other  Billing and Payments
Other  Billing and Payments