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California Workers' Comp
URINE DRUG SCREEN    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CT SCAN = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
EMG/NCS   = 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)
8 WEEK 24 LESSON COURSE  IN WORK COMP
TREATMENT AND COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE STAFF)
6 Month  24 LESSON
COURSE  IN WORK COMP
TREATMENT AND
COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE
STAFF)
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
CONSULT WITH PAIN MANAGEMENT = 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
PSYCHOLOGICAL EVALUATION = 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
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 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 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:
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>

 

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

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
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
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
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
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

Urine Drug Screening Billing and Payments in 2015 Who's Right and Why.

Saturday, August 8, 2015

2:30 PM

    Urine Drug Screening Billing and Payments in 2015 Who's Right and Why

    The Issues:

    1. Only a limited number of Payers are paying the 80300 series as billed
    1.   Other payers  will not pay anything on the 80300 series stating it has no value.
    1. For billing on the new 2015 G series, Medicare accepting and Paying more value than what IBRs are stating should be bundled
    1. California IBR decisions,  of which California  Providers have to resolve there payment dispute, are still using 2012 Medicare fee schedule for G0431 and bundling all coding.
    1. California IBR recently issued  decision and bundled  all 2015 G series codes under G0431 at $119.00

    Solutions:

    1.  80300 has a value under worker comp laws, therefore rejections of no payments are incorrect
    1. IBRs are in error in  bundling  all code under G0431 and medicare already stated this in  2014, not all are bundled
    1. Have to overcome incorrect IBR decisions  using present law to overcome improper objections and IBR decisions
    1. Providers have to understand the Coding to overcome incorrect  objections and  know how to Appeal incorrect IBR decisions, as they are using wrong laws to bundled all under G0431
    1. Medicare is aware, the changes, that the 2011 changes in coding to G0431 etc.,  did not result in reasonable reimbursement.
    1. G0431 in most  circumstances are  incorrect as being applied by IBR decisions.
    1. Not getting or understanding the laws and methods to contest underpayments  or no payments, if it the only issue is amount of payments closes the door to contest the amount of underpayments -- i.e. no redress -- So sitting on wrongfully reduced bills does not bring about reasonable reimbursement.

     California Work Comp:

    Can bill the 80300 series if documentation justifies, however one has to apply the work comp rules to apply a monetary value  for payment of those codes.

    Can Bill the G series, but once again,  most payers will copy what IBR decisions reflect and most providers are not understanding the codes as of yet to warrant a positive decision other than bundling under G0431 at $119.00 or thereabouts.

    ANALYSIS AND FINDING

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

    ·ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes 81002, 82570, G6040, G6039, 80500, G6036, 80184, G6037, G6053, G6034, G6032, G6030, G6052, G6031, G6045, G6046, G6043, G6056 & 83789

    ·Provider states the services were for quantitative drug testing, not qualitative high complexity. Services were for a drug screening of high complexity.

    ·Claims Administrator denied codes indicating on the Explanation of Review “We are unable to recommend an additional allowance as your billing was reviewed in accordance with the Official Medical Fee Schedule of California, which was adopted by the Administrative Director of the Division of Industrial Accidents for Workers’Compensation Claims”

    ·Moderate v. High complexity as defined by Centers for Disease Control Clinical Laboratory Improvement Amendments (CLIA), “Clinical laboratory test systems are assigned a moderate or high complexity category on the basis of seven criteria given in the CLIA regulations. For commercially available FDA-cleared or approved tests, the test complexity is determined by the FDA during the pre-market approval process. For tests developed by the laboratory or that have been modified from the approved manufacturer’s instructions, the complexity category defaults to high complexity per the CLIA regulations, See 42 CFR 493.17

    High complexity of the toxicology test performed; results reporteda computerized measure of each drug screened which the Provider did submit. ·Quantitative Levels: A drug can be detected ina donor's sample andstill be reportedasnegative. A laboratory has what iscalled, "cutoff levels". These levels are designed toscreenout some over?the?counter pharmaceuticals or vitamins. ·Due to the complexity of the toxicology test performed,the laboratory services shall be paid in accordance with HCPCS code G0431.

    ·Upon review of Centers for Medicare & Medicaid Services (CMS) guidelines, HCPCS code G0431 is reported with only one unit of service regardless of the number of drugs screened. The testing described by G0431 includes all CLIA high complexity urine drug screen testing as well as any less complex urine drug screen testing performed at the same patient encounter.

    ·Disputed Codes 82055 is not inclusive to G0431 and it is recommended that the code be reimbursed separately in accordance with Title 8, California Code of Regulations, §9789.50 Laboratory Fee Schedule.

    ·Based on information reviewed, reimbursement of G0431 is warranted.

    Analysis and Findings:

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

    ·ISSUE IN DISPUTE: Provider dissatisfied with reimbursement of billed codes 82055, 82205, 82145,80154, 80299-59, 82520, 80299-59, 83840, 83925-59, 83986, 83992, 81002, 80152.

    ·Provider was reimbursed $21.59 and is seeking additional reimbursement of $266.34.

    ·Claims Administrator bundled the billed codes82205, 82145, 80154, 80299 59,82520,80299 59,83840, 83925 59, 83992 and 80152into HCPCS G0434 indicating thefollowing on the Explanation of Review(EOR): “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.”

    ·The Provider submitted a copy of the laboratory test results and Provider’s Clinical Laboratory license. The toxicology results submitted report a quantitative measure of each drug screened (Amphetamine, Barbiturates, Benzodiazepine,Cannabinoids,Cocaine Metabolites, Ecstasy, Methadone Metabolite, Opiates, Oxycodone,PCP, Tricyclics), . HCPCS code G0434 is utilized to report urine drug screening performed by a test that is CLIA waived or moderate complexity test. Due to the complexity of the toxicology test performed, the levels tracked and results obtained the billed procedure codes 82205, 82145, 80154, 80299 59,82520,80299 59,83840, 83925 59, 83992 and 80152shall be paid in accordance with HCPCS code G0431. The HCPCS code G0431 is reported with only one unit of service regardless of the number of drugs screened. The testing described by G0431 includes all CLIA high complexity urine drug screen testing as well as any less complex urine drug screen testing performed at the same patient encounter.·The description of HCPCS code G0431 is "Drug screen, qualitative; multiple drug classes by high complexity test method (e.g. immunoassay, enzyme assay), per patient encounter."

    ·The drug screen services provided were of high complexity test method. The HCPCS code G0431 criteria has been met based on the documentation submitted by the Provider. Therefore, the code assignment G0434 and payment made by the Claims Administrator was not correct.

    ·The billed procedure code CPT 83986, 81002 and 82055 are not considered part of the drug panel and should be paid separately. The description of CPT 83986 is "pH; body fluid, not otherwise specified." The description of CPT 81002 is " Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy ." The description of CPT 82055 is " Alcohol any specimen except breath.”·PPO Contract was received and a 10% discount is to be applied.

    ·DETERMINATION OF ISSUE IN DISPUTE: Based on the documentation submitted, additional reimbursement of $111.51to be madebased on the Official MedicalFee Schedulefor HCPCS code G0431, 83986, 81002 and 82055

    ANALYSIS AND FINDING

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

    ·ISSUE IN DISPUTE: Provider seeking additional remuneration for 82486 Gas/liquid chromatography Drug Testing Performed on 02/18/2015.

    ·Claims Administrator reimbursement rational based on “unauthorized” service.

    ·Authorization for “Urine Toxicology Screen”indicates “Approved by Physician Advisor,”on 01/23/2015.

    ·Pursuant to Labor Code section 5307.1(g)(2), the Administrative Director of the Division of Workers’ Compensation orders that the pathology and clinical laboratory fee schedule portion of the Official Medical Fee Schedule (OMFS) contained in title 8, California Code of Regulations, section 9789.50, has been adjusted to conform to the changes to the Medicare payment system that were adopted by the Centers for Medicare & Medicaid Services (CMS) for calendar year 2014. Effective for services rendered on or after January 1, 2013, the maximum reasonable fees for pathology and laboratory services shall not exceed 120% of the applicable California fees set forth in the calendar year 2012 Clinical Laboratory Fee Schedule. Based on the adoption of the CMS payment system, CMS coding guidelines and fee schedule were referenced during the review of this Independent Bill Review (IBR) case

    .·CMS 1500 reflect 82486x17

    ·Moderate v. High complexity as defined by Centers for Disease Control Clinical Laboratory Improvement Amendments (CLIA), “Clinical laboratory test systems are assigned a moderate or high complexity category on the basis of seven criteria given in the CLIA regulations. For commercially available FDA-cleared or approved tests, the test complexity is determined by the FDA duringthe pre-market approval process. For tests developed by the laboratory or that have been modifiedfrom the approved manufacturer’s instructions, the complexity category defaults to high complexity per the CLIA regulations, See 42 CFR 493.17.·A similar code historically assigned for CPT 82486 is G0431“multiple drug classes by high complexity test method.”

    ·As defined by the US Centers for Medicare and Medicaid Services (CMS), HCPCS G0431 is defined as follows: G0431 (Drug screen, qualitative;multiple drug classes by high complexity test method(e.g., immunoassay, enzyme assay), per patient encounter) will be 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. This code may only be reported if the drug screen test(s) is classified as CLIA high complexity test(s) with the following restrictions:omay only be reported when tests are performed usinginstrumented systems (i.e., durable systems capable of withstanding repeated use).oCLIA waived tests and comparable non-waived tests may not be reported under test code G0431; they must be reported under test code G0434.oCLIA moderate complexity tests should be reported under test code G0434 with one (1) Unit of Service (UOS).oG0431 may only be reported once per patient encounter.

    ·Lab Report for date of service reflects high complexity computerized analysis.

    ·Reimbursement is warranted for 82486as G0431 x 1 unit.

    ·Contractual Agreement not available for IBR, 100% OMFS will be utilized.

    Conclusions: In 2014 and 2015 one does not have to play the billing code game to get reasonable reimbursement, one just has to understand the 2015  and 2014 Medicare and how work comp puts a reasonable value.  In addition and this has been the issue since 2013, not all coding is bundled under G0431 and this is a major issue with  Providers in billing, lack of correct documentation and assertion of  appropriate laws, simple error causing major losses.

    The HCPCS codes listed below are new for 2015 and are subject to CLIA edits. The list does not include new HCPCS codes for waived tests or provider-performed procedures. The HCPCS codes listed below require a facility to have either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid, current, CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2) or with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) must not be permitted to be paid for these tests.

    • G0464 - Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3)

    • G6030 – Amitriptyline;

    1. • G6031- Benzodiazepines;
      • G6032 – Desipramine;
      • G6034 – Doxepin;
      • G6035 – Gold;
      • G6036 – Assay of imipramine;
      • G6037 – Nortriptyline;
      • G6038 – Salicylate;
      • G6039 – Acetaminophen;
      • G6040 – Alcohol (ethanol); any specimen except breath;
      • G6041 – Alkaloids, urine, quantitative;
      • G6042 – Amphetamine or methamphetamine;
      • G6043 – Barbiturates, not elsewhere specified;
      • G6044 – Cocaine or metabolite;
      • G6045 – Dihydrocodeinone;
      • G6046 – Dihydromorphinone;
      • G6047 – Dihydrotestosterone;
      • G6048 – Dimethadione;
      • G6049 – Epiandrosterone;
      • G6050 – Ethchlorvynol;
      • G6051 – Flurazepam;
      • G6052 – Meprobamate;
      • G6053 – Methadone;
      • G6054 – Methsuximide;
      • G6055 – Nicotine;
      • G6056 – Opiate(s), drug and metabolites, each procedure;
      • G6057 - Phenothiazine;
      • G6058 - Drug confirmation, each procedure;
      • 80163 - Digoxin level;
      • 80165 - Valproic acid level;
      • 80300 - Drug screen;
      • 80301 - Drug screen;
      • 80302 - Drug screen;
      • 80303 - Drug screen;
      • 80304 - Drug screen;
      • 80320 - Alcohols levels;
      • 80321 - Alcohols levels;
      • 80322 - Alcohols levels;
      • 80323 - Alkaloids levels;
      • 80324 - Amphetamines levels;
      • 80325 - Amphetamines levels;
      • 80326 - Amphetamines levels;
      • 80327 - Anabolic steroids levels
      • 80328 - Anabolic steroids levels
      • 80329 - Analgesics levels;
      • 80330 - Analgesics levels;
      • 80331 - Analgesics levels;
      • 80332 - Antidepressants levels;
      • 80333 – Antidepressants levels;
      • 80334 – Antidepressants levels;
      • 80335 – Antidepressants levels
      • 80336 – Antidepressants levels;
      • 80337 - Antidepressants levels;
      • 80338 – Antidepressants levels;
      • 80339 - Antiepileptics levels;
      • 80340 – Antiepileptics levels;
      • 80341 – Antiepileptics levels;
      • 80342 – Antipsychotics levels;
      • 80343 – Antipsychotics levels;
      • 80344 – Antipsychotics levels;
      • 80345 – Barbiturates levels;
      • 80346 - Benzodiazepines levels;
      • 80347 – Benzodiazepines levels;
      • 80348 – Buprenorphine level
      • 80349 – Cannabinoids levels
      • 80350 - Cannabinoids levels
      • 80351 - Cannabinoids levels;
      • 80352 - Cannabinoids levels;
      • 80353 – Cocaine level;
      • 80354 – Fentanyl level;
      • 80355 – Gabapentin level non-blood;
      • 80356 – Heroin metabolite level;
      • 80357 – Ketamine and norketamine levels;
      • 80358 – Methadone level;
      • 80359 – Methylenedioxyamphetamines levels;
      • 80360 – Methylphenidate level;
      • 80361 – Opiates levels;
      • 80362 – Opioids levels;
      • 80363 – Opioids levels;
      • 80364 – Opioids levels;
      • 80365 – Oxycodone levels;
      • 80366 – Pregabalin level;
      • 80367 – Propoxyphene level;
      • 80368 – Sedative hypnotics (non-benzodiazepines) levels
      • 80369 – Skeletal muscle relaxants levels;
      • 80370 – Skeletal muscle relaxants levels;
      • 80371 – Synthetic stimulants levels;
      • 80372 – Tapentadol level;
      • 80373 – Tramadol level;
      • 80374 – Stereoisomer (enantiomer) drug analysis;
      • 80375 – Drugs or substances measurement;
      • 80376 – Drugs or substances measurement;
      • 80377 - Drugs or substances measurement;
      • 81246 - Test for detecting genes associated with blood cancer;
      • 81288 - Test for detecting genes associated with colon cancer;
      • 81313 - Test for detecting genes associated with prostate cancer;
      • 81410 - Test for detecting genes associated with heart disease;
      • 81411 - Test for detecting genes associated with heart disease;
      • 81415 - Test for detecting genes associated with diseases;
      • 81416 - Test for detecting genes associated with disease;
      • 81417 - Reevaluation test for detecting genes associated with disease;
      • 81420 - Test for detecting genes associated with fetal disease;
      • 81425 - Test for detecting genes associated with disease;
      • 81426 - Test for detecting genes associated with disease;
      • 81427 - Reevaluation test for detecting genes associated with disease;
      • 81430 - Test for detecting genes causing hearing loss;
      • 81431 - Test for detecting genes causing hearing loss;
      • 81435 - Test for detecting genes associated with colon cancer;
      • 81436 - Test for detecting genes associated with colon cancer;
      • 81440 - Test for detecting genes associated with cancer of body organ;
      • 81445 - Test for detecting genes associated with cancer of body organ;
      • 81450 - Test for detecting genes associated with blood related cancer;
      • 81455 - Test for detecting genes associated with cancer;
      • 81460 - Test for detecting genes associated with disease;
      • 81465 - Test for detecting genes associated with disease;
      • 81470 - Test for detecting genes associated with intellectual disability;
      • 81471 - Test for detecting genes associated with intellectual disability;
      • 81519 - Test for detecting genes associated with breast cancer;
      • 83006 - Test for detecting genes associated with growth stimulation;
      • 87505 - Detection test for digestive tract pathogen;
      • 87506 - Detection test for digestive tract pathogen;
      • 87507 - Detection test for digestive tract pathogen;
      • 87623 - Detection test for human papillomavirus (hpv);
      • 87624 - Detection test for human papillomavirus (hpv);
      • 87625 - Detection test for human papillomavirus (hpv);
      • 87806 - Detection test for HIV-1;
      • 88341 - Special stained specimen slides to examine tissue;
      • 88344 - Special stained specimen slides to examine tissue;
      • 88364 - Cell examination;
      • 88366 - Cell examination;
      • 88369 - Microscopic genetic examination manual;
      • 88373 - Microscopic genetic examination using computer-assisted technology;
      • 88374 - Microscopic genetic examination using computer-assisted technology; and
      • 88377 - Microscopic genetic examination manual.

     

    see more at: www.workcompliens.com

     

    Toxicology / Urine Drug Screening

     

     

    see more at: www.workcompliens.com

     

    Toxicology / Urine Drug Screening

     

     

 

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WC: When Liens are Not Required, Nor Subject to the Time to File Liens

Monday, August 10, 2015

7:42 AM

 

Three years into SB 863 and we are seeing more and more Providers using other laws and methods under SB 863,  to get orders for payments without the necessity of filing liens and or subject to the time to file liens. Of which most are producing better and or more expediency of results.

1.  Providers' services are denied based on the issue of treatment outside the MPN. The applicant attorney  does a expedited hearing and the Court rules insufficient offer of treatment, treatment outside the MPN allowed at employers expense. All providers in that case can now either request and get a order for payment without a lien filed or time limits, depending what the EOR  stated.

2. Copy services files a "Petition for Non-IBR Medical Legal Disputes",  as services medical legal, just by the filing of the Petition allows the Provider to recovery without a lien and or lien time limit.  This applies to all providers doing a medical-legal.

3. The case is a denied based on the defense of "Post Termination",  Lien Claimant does a lien trial, judge holds that employer had notice of the injury prior to termination, other providers who have not filed a lien or past the time to file can now get an order for payments, depending on the what the EOR states either through the IMR or IBR process (or second review).

4. Petition for Costs

5. The case denied, case in chief admitted injury Providers can get orders for payments without lien and or lien fees.

6. Case denies the psych injury, Psych Provider does  a Medical -Legal, even though not a QME or AME, The provider if no payments made,  can do a "Petition for Non-IBR Medical Legal Dispute." This also applies to testing, evaluations, as well as AME and QME.

7.If the Defense in an admitted claim and denied body part  defers UR, when the issue is resolved but treatment already provided, a mandatory UR has to take place, no lien or  time to file liens required.

There are 10 more examples where SB 863 set a system up  where liens and or time limits of liens are not mandated, even Petitioning the Director for enforcement. However just like all laws under SB 863, it requires  detail and understanding of how the above Procedures  work and their applications.

There are a good number of laws that most Providers are starting to utilize under SB 863. 

The Provider was asked to perform a psychiatric consultation and submit a report on the injured worker for the purpose of clearance for surgery.

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August 14 New Fee Schedule Issues Posted

WC: Urine Drug Testing in Pain Management/ Authorization and Payments

Friday, August 14, 2015

7:24 PM

 

 

Urine drug testing (UDT) has become “an essential feature of pain management, as physicians seek to verify adherence to prescribed opioid regimens and to detect the use of illicit or unauthorized licit drugs.”

 

Although, the medical necessity of UDT is essential in monitoring pain management with pain   medication, the payments or these tests, outside billing for Medicare has gone from one extreme to another, accountable by no less of  the publicized asserted abuse and actual abuse on the money side of these services.

 

I read one article that stated a Doctor was testing all senior citizens for cocaine, as an example for abuse, however for industrial injuries testing for cocaine is a must, therefore some of the publicized abuses do not fit the same for injured workers.

 

Medical Necessity:

 

We have four sources that reference medical necessity for Urine Drug screening:

 

  1.   CA MTUS Chronic Pain 2009 Guidelines. MTUS Chronic Pain Guidelines support the use of urine drug screening to monitor for issues of abuse when treating with chronic narcotic pain medications. No set frequency is specifically recommended per the guidelines.

 

  1. MTUS Chronic Pain Guidelines section on opiates--steps to avoid misuse/addiction--frequent random urine toxicology screens are recommended in particular for those at high risk of abuse. MTUS pages94-95 for "Steps to avoid opioid misuse", recommend frequent random urine toxicology screens

 

  1. ODG guidelines on Urine Toxicology screening state the following: Indications for UDT: At the onset of treatment: (1) UDT is recommended at the onset of treatment of a new patient who is already receiving a controlled substance or when chronic opioid management is considered. Urine drug testing is not generally recommended in acute treatment settings (i.e. when opioids are required for nociceptive pain). (2) In cases in which the patient asks for a specific drug. This is particularly the case if this drug has high abuse potential, the patient refuses other drug treatment and/or changes in scheduled drugs, or refuses generic drug substitution. (3) If the patient has a positive or "at risk" addiction screen on evaluation. This may also include evidence of a history of comorbid psychiatric disorder such as depression, anxiety, bipolar disorder, and/or personality disorder (4) Ifaberrant behavior or misuse is suspected and/or detected. Ongoing monitoring: (1) If a patient has evidence of a "high risk" of addiction (including evidence of a comorbid psychiatric disorder (such as depression, anxiety, attention-deficit disorder, obsessive-compulsive disorder, bipolar disorder, and/or schizophrenia), has a history of aberrant behavior, personal or family history of substance dependence (addiction), or a personal history of sexual or physical trauma, ongoing urine drug testing is indicated as an adjunct to monitoring along with clinical exams and pill counts (2) If dose increases are not decreasing pain and increasing function, consideration of UDT should be made to aid in evaluating medication compliance and adherence.

 

  1. Published Medical Papers such as Urine Drug Testing as an Evaluation of Risk By Ted Jones, PhD, James D. McCoy, FNP-BC, Todd Moore, PhD and Susan Daffron, FNP ---While some studies seek solely to identify the presence of illicit or unauthorized prescription substances, the absence of a prescribed opioid medication—hereafter described as an “unexpected negative” finding—also raises a variety of clinically relevant possibilities:

 

  1. • patient never took the medication
    • patient took the medication but was for some reason unable to absorb the medication
    • patient took the medication but for some reason was unable to excrete the medication or its metabolites
    • patient last took the medication too many hours before the test for a detectable level to be present
    • patient lost the medication
    • patient sold or otherwise illicitly distributed the medication
    • medication was stolen
    • any combination of possibilities

 

The standard urine toxicology/drug screen is qualitative, will be able to tell what  drugs are  in your system ==quantitative tells the quantity

 

  •  Initial Screening An initial Enzyme Immunoassay (EIA) test screens for the presence of opiates, benzodiazepines, illicits and other prescribed or non-prescribed medications.

 

  • Confirmation Testing If the EIA test result is positive, the sample undergoes confirmation testing through one of the following methods:

 

  • Gas chromatography-mass spectrometry (GC/MS) is used to create a fingerprint-like match for each detected prescription medication or illicit. This technology’s superior sensitivity can detect drugs or metabolites at some of the lowest levels in the industry.

 

  • Liquid chromatography – tandem mass spectrometry (LC/MS/MS) is used when optimal specificity and sensitivity are required to determine the absence or presence of your patients’ prescribed medications as well as the presence of non-prescribed medications or illicit.

 

As to medical necessity in pain management testing in most case should be authorized as it is essential in any and all use of  medications.

 

Payments:

 

To survive the payment disputes regarding UDT for industrial injuries, one has to have enough law to justify a reasonable reimbursement for all carries as payments vary, with the majority on the low side.

Not only is knowing the laws to  justifying a uniformity of payments based on Medicare ground rules, but one has to understand the processes in industrial injury cases to bring to light those disputes to resolve payments in a set uniformity of reasonable payments.

 

In short, some Providers are getting a mix of payments, with the norm being 10 percent or less paying reasonable and 80 to 90% paying unreasonable, resulting in not finding what is reasonable reimbursement, end result substantial losses.

In 2015, if the law states one should be paid a certain amount, the acceptance of less, because of lack of understanding the laws and or how to get reasonable payment when paid incorrectly, makes little sense, but that is essentially where most are, in the billing and payments of UDT.

 

In short most are stilling playing the coding game, hitting pay dirt with some payers, while the majority of their accounts and services substantially underpaid. As just what has been happening in the last three years those codes will be rebooted and back to 100% paying unreasonable,  luck of billing codes do not pay off in the long run. One has to understand and justify the payment system. The question is not what billing codes are paying reasonable, but why are they and why are some paying the same code unreasonable , and why are IBRs stilling bundling all codes under G0431, master those 3 questions and one can achieve uniformity of reasonable payments and actually make a justifiable legal argument if the issue has to be resolved by a dispute forum  that rules on those matters..

 

Medicare changed the coding and  the reimbursement, because the interpretation of bundling everything under G0431 dd not bring about reasonable reimbursement and or was being interpreted incorrectly, not because those codes were working, if they were, changes would not have been made. However, the key, because the several changes, is on the Provider to justify reasonable reimbursement for all billing,  for all payers that  equate payments based on Medicare reimbursement rules.

 

In industrial injuries, one is right in billing any adopted billing codes as long as the services are actually performed, i.e. the 80300 codes although Medicare has not put a value  to those and requires the 2015 G series . For example those billing the 80300 series do not understand the laws as to why a small percent are paying well on 80300 series and how to bring all their services up to the same reimbursement level for all payers. They actually think it is an error by payers, which is an incorrect conclusion  on their part. resulting in a lost of 80% of their services.

 

Payments .for urine drug screening has a many opinions as there are billing codes. I have even read one post where they stated the new codes were for identification purposes and not payments, that is clearly what Medicare is not stating.

Medicare allows the G series codes unbundled, unless specifically stated  as bundled under G0431 or G0434 which are few compared to those that are not bundled. Therefore billing both  the G0431 and the G series when tests are warranted.

Some States have adopted their  own fee schedule regarding payments for urine drug screen, while a few make there reimbursement based on Medicare payments. Example, Texas who uses Medicare is very liberal in payments never bundling any codes but each one separately payable including recognizing 82486.

 

California has one of the lowest reimbursement over the last three years, basically because insurance companies follow the reimbursement rates decided by IBR decisions , in which they have consistently bundled  every billing code under G0431 - However in 2014/2015 Medicare clarified what was bundled under G0431 and which was not:

 

The below is an example of an IBR decisions in which it was incorrect in bundling all codes under G 0431:

A posted IBR (independent Bill review) decision errors in bundling  all the following codes under G0431= $119.95:

 

81002, 82570, G6040, G6039, 80500, G6036, 80184, G6037, G6053, G6034, G6032, G6030, G6052, G6031, G6045, G6046, G6043, G6056 & 83789,  The is not what Medicare states these codes should be paid.

Not taking into consideration the medical necessity of the tests or the documentation submitted by the Provider in this case, the review should have been as follows under Medicare payments system;

The Provider should have billed G0431 for the following bundled codes:

 

• Bundled =qualitative =G6052, Meprobamate = Meprobamate, qualitative analysis Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

• Bundled G6045, Dihydrocodeinone = Dihydrocodeinone, qualitative Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

• Bundled G6046, Dihydromorphinone Dihydromorphinone, qualitative Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

• Bundled G6043 Barbiturates, not elsewhere specified Barbiturates,

Qualitative Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

 

The below billing codes / tests are not bundled under G0431 but have a separate money  value. The Provider in addition to billing G0431 for the bundled codes, should have billed the below unbundled codes each with a separate payable value, if justified by medical necessity of the test or authorization, based on the billing codes the provider submitted in this case.

 

• Not Bundled =81002, = G6058 = Drug confirmation, each procedure = $

• Not Bundled= G6040,= Alcohol (ethanol); any specimen except breath= $

• Not Bundled G6039= Acetaminophen = $

• Not Bundled G6036, Imipramine = $

• Not Bundled G6037, Nortriptyline = $

• Not Bundled G6053, Methadone = $

• Not Bundled G6034, Doxepin = $

• Not Bundled G6032, Desipramine = $

• Not Bundled G6030, Amitriptyline = $

• Not Bundled G6031, Benzodiazepines = $

• Not Bundled G6056 Opiate(s), drug and metabolites, each procedure = $

 

If the Provider billed correctly and submitted the required documents, the decision to bundled all bill codes under G0431 is incorrect for dates of services in 2015 and 2014.

 

In this case the Provider should have appealed the IBR decision with the correct law.

by: www.workcompliens.com

 

 

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Liens Filing, No Liens, Exceptions, Time Limits, MPNs Denied Cases etc

Sunday, August 16, 2015

5:22 PM

"Introduction to 2015 Book Lien Filings, Exceptions and Time Limits, MPNs Denied Cases and Contested Liability Issues"

 

With the complications of SB863, there are numerous laws that Providers have not  used that benefit them beyond comprehensive.

 

SB 863 has  several pieces of laws that fit with other pieces of laws and used in different ways,  depending on the issues or other laws they attach, to create laws and results that have never been  used , that benefits for Providers.

 

It can best be compared to a mechanical device, a piece is added, it produces a different function and or a piece is taken away, again  another function is created.  This is how SB 863 functions, with many different extensions that has the main purpose to ensure  the injured worker gets the treatment necessary and the Providers gets paid fee schedule. The obstacles  such as liens, fees and IBR fees are meant to be  isolated paths, as there are many other paths to enforce.

 

Example of complexities without even touching SB 863:

 

  1. Provider states adjuster will not pay because the services were  certified by UR  as medically necessary but not authorized because of MPN issue (hospitals facility)
  1. I attach the 2007 En Banc Cervantes decision which stated for spinal surgery if certified as medically necessary has to authorize. (Prior to 2012 different rules regarding UR and authorization for spinal surgery as an exception to all others services)
  1. I attach SB 863 that states and  which invalids the Cervantes case because of the IMR process and regulated out in 2012.
  1. I attach that most if not all MPNs list all Hospitals as MPNs because the PPO discounts, so always listed even when the Hospital has no MPN contract.
  1. I attach SB 863 which states those part of MPN have to acknowledged being part of that MPN, most Hospitals did not do this.
  1. I attach that if the UR certification did not notify the injured worker which MPN hospital to go to,  the non MPN hospital can treat outside.

 

As one can see by the  illustration, that each time I attached a law, a different function and result took place, and that is more often under SB 863 than the above example. The key is to know which laws to make an issue functional and to achieve the desired results under the laws, that is were we get into less disputes and or if disputes better results. As to the above example, over $60,000.00 was either added to the Provider or taken away, depending on what law (extension )  I attached, including based on the law attached whether lien or no lien required, i.e, order without a lien or time to file. This attachment of different laws, causing different results applies to all services and  specifically no need or no need to file liens which we will show in detail in the coming chapters.

 

This is were most Providers fail,  believing treating on UR denials and playing with billing codes produces better results than learning and applying the many paths of SB 863.

 

At the start of 2013 most found SB 863 to complex and had not felt the result on not utilizing  it to its' full intent. However, in 2015 most are seeing that ignoring SB 863 is costly and at this point foolish.

 

There exist two paths of SB 863, one that allows a Provider to avoid the necessity of filing liens, to get paid fee schedule without disputes and to file certain services and products by petition. Then we have the second path that is filled with pitfalls that results in a great expense and less productive results which most are following today.

 

Before we show the laws and or interaction of other laws, we will summarize the simplicity of laws that benefit providers but yet to be explored by Providers.

 

It is important to note, that the below is a summary introduction to the 2015 Book, we will go into detail citing law with each chapter of this book, knowing that the law is not enough,  one must be able to show the law and why it states what one asserts its states.

 

Examples:

 

1. 20 to 30%  of all EORs that stated authorization was denied are incorrect and in addition there are a category of services that do not require authorization, i.e., office visit new, x-rays when the injured worker suffered a fall, authorization is not required or when an AME / PQME requests consultation or testing, no authorization by the adjuster required, many examples in upcoming chapters

Below, a few examples from actual cases:

 

• Provider billed CPT codes 62289, 76499-26-59, and 76003-26-59.

Explanation of Review (EOR) from the Claims Administrator denied the claim for the following reasons: “This charge is denied as the service was not authorized during the utilization review process.” A second review resulted in the same denial.

o Upon Review of the documentation provided, a document entitled “Overriding UR Denial,” dated 5/9/13 by the “Sr. Claims Examiner,” is present

 

• Reimbursement of codes 62367, 99081, 99214-25, and 99401

The Claims Administrator denied the $870.00 service charge for the following reason, “This charge or service was not authorized...”

o Authorization for CPT 62367 is included in the documentation provided for this review.

o Authorization date December 17, 2013 entitled “Notification of Certification” from the Claims Administrator states, “62637 x8 (8 pump refills)and Maintenance has been determined to be medically necessary.” Dates of authorization are 12/10/13 through 03/10/14.

 

• ISSUE IN DISPUTE: Provider disputing $0.00 reimbursement for ML104 Services, date of Service May 9, 2013.

o Claims Administrator denied ML104 services stating“services not authorized.”

o Authorization for Med-Legal services from (Legal Parties) dated 02/18/2013, addressed to the Provider authorizing examination of Injured Worker as the “Qualified Medical Examiner,” for date of service, “April 02, 2013.

 

• ISSUE IN DISPUTE: Provider seeking full remuneration for Functional Restoration Program services, billed as Unlisted Evaluation and Management Procedure Code 99499-86 for each date of service 06/30/2014 –07/09/2014.

o The Claims Administrator reimbursed the Provider $0.00 of $4,480.00with the following rational: “Service not authorized.”

o Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.

o Authorization for Functional Restoration Program presented for IBR, dated June 16, 2014 signed by the Claims Administrator Physician Reviewer indicates treatments “Authorized,”meeting the criteria for Modifier -86.

 

The above is a few examples out of hundreds and in fact 100s of thousands of such issue are flooding Providers on EORs, saying not authorized when in fact it was authorized or did not need authorization.

 

Therefore, those who are not aware of this practice by insurance companies, sends authorized services to a lien instead of getting paid fee schedule, this is a big issue with Providers using collection companies as most Providers do not identify what files were authorized services and  collections companies, most of the time cannot get the UR decisions.

 

Next the system was set up so liens do not need to be filed.

 

SB 863 was enacted so that all services would be subject to the IMR and or IBR process, meaning if a case is denied initially and order is had resolving that issue, expedited hearings for MPNs or other lien hearings and or how the case in chief was resolved (wording on the compromise and release) meaning now the dispute of Providers services can go to UR or second review and get orders for payments from those two process.

 

 Now this can apply to prior to 2013 dates of services but clearly those in 2013.

 

In addition, there is a Petition that allows one to mandate a UR take place to enforce the requirements that an adjuster does a retrospective review when n order resolve a contested liability issue, which few use or are aware of. Then we actually have the law that allows the consent of the adjuster to send through UR.

Then we have medical legal services “Petition for Non-IBR Medical Legal”, which requires no lien or lien time limit, then we attach case law that has expanded the interpretation of what medical-legal services are, a large part of providers services would not be subject to the lien, in denied cases.

 

Then we MPNs, over the past two years a great deal of case law has been created related regarding MPNs especially ancillary services or where a referral is by a non-MPM provider. A large part of Providers are settling low or filing liens on MPN issues and missing the laws regarding these issues to get paid fee schedule. Also we have issues when the Provider is not objected to an PTP that overcomes MPN issues.

We will also show a 62 check list of issues regarding MPN based on case and statutory law that the defense must comply with.

 

Lastly, we have the many laws attached to the IMR process and appeals that treating on UR is not productive and unnecessary under SB 863, allowing orders without liens or time limits.

 

Then we have side laws, notice of intent to file a lien, and filing to allow assess to eams without filing a lien.

 

The main issue is that all we will discuss in the following chapters, it is the Provider and the Providers staff that  makes the extreme financial difference under SB 863.

 

The above is just an introduction summary to the 2015 Liens Book of laws most are not using, in the preceding chapters we will state and show the laws that interact to show the above and more including many factual examples and how to bring about fee schedule without liens and or IBR fees.

 

by: www.workcompliens.com

 http://www.workcompliens.com/9-Web-Open-Lien-Issues.html

 

 

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Clinical Laboratories, Urine Drug Screening Payments In California Work Comp / Medicare, Challenges

Sunday, August 23, 2015

7:30 AM

Just like when insurance companies mistakenly  pay a service at higher value, it takes those insurance companies sometimes a long time to adjust, so  is the opposite also true, when they have been paying something at a low value that warrants a higher value, it takes time to adjust.

 

California Workers'  Comp,  is based on Medicare billing codes and guidelines, for urine drug screening, which in turn has caused  this  ever changing reimbursement rates for  urine drug screening.

 

We have seen the G0431 / G04343, the 82486, the Codes 80300 through 80377 (63 codes) and the alphanumeric G codes to replace the 2014 CPT codes that are being deleted for 2015.

 

Basically, what Medicare stated was that the G0431 and G0434 did not equate to reasonable reimbursement by bundling all under those codes. They also held that the  80300 through 80377  were to many codes, opening up for possible abuse of billing, so they sent a compromise for billing codes in 2014 and 2015, which landed somewhere in the middle.

So in 2015, we have the alphanumeric G codes, that clarified not all billing codes are bundled under G0431 or G0434 also designated  codes for 2014 billing.

 

What we have seen, is that some insurance companies have been paying the  80300 through 80377  at high value,  a few, not many.

 

  State Compensation Insurance Fund (SCIF) has announced it is fixing its' bill review program and will no longer pay those codes 80300 through 80377  . Note, we saw this last year, that towards October, a great change took place with most insurance companies bill review programs updated.

 

Therefore, the correct billing codes for 2015 are the alphanumeric G codes and for 2014, those codes put forth by Medicare.

 

Now one may think, finally, clarity for billing for urine drug screening, things should  be simple, far from the truth.

Lets say under the 2014 and 2015 Medicare billing codes that the fee schedule has gone back up to $1,200.00, depending  on the tests, qualitative, quantitative, authorization , medical necessity etc.

 

Now what will happen and is happening, is that payments will be at  $59.00, or all bundled under G0431 for a $119.95, with settlements sometimes as high as $250.00.  That means a clinical laboratories, let's say, does a 100 tests a day could, thereby they would be losing a $100,000.00 a day. We have already seen this with a recent IBR decision which took the 2015 alphanumeric G codes  and bundled them all under G0431 at 119.95.

 

The why of the above statement , is that most insurance companies have created a practice of paying and reviewing most below fee schedule and kind of daring the Providers to jump through the maze of laws to show they are entitled to more, and this failure to accomplish the hurdle of laws, has never been more present that it has with urine drug screening.

Not only does one have to overcome  MPN issues, authorization issues, denied case issues, IMR issues but more importantly the IBR process.

 

The IBR reviewers,  have the stone wall of IBR decisions who will not and have not let one urine drug screen above $119.65 pass for the past last three years, which means those billing for urine drug screen have to know the laws why they are entitled to more. Having to submit the correct documents and laws to convince the IBRs, because most insurance companies will not change on the $59.00 or $119.95, mandating the IBR process.

 

In the end result, the large majority of urine drug screen will and are still being paid at $59.00 and or $119.95, as it takes much more than just having the correct billing codes.

 

In fact this is a major issue in California work comp for providers, just taking what is being  paid and attempting  to settle for a few more dollars, with a large portion of these receivables, because of lack of knowledge how to follow the rules to bring about reasonable reimbursement, creating larges losses. 

 

The purpose and intent of SB 863 was to put disputes to rest early, medical necessity 30 days to an IMR, fee schedule issues 90 days to do a second review and 30 days to an IBR, 18 months to file a lien for dates of services on or after July 01, 2013.  All meaning, if you do not take that window to yell foul, you are stuck with that foul.  What this has caused for most Providers, is millions of dollars in receivables that are SB 863 violated , although we have  not yet seen its full enforcement of time defaults, although some have, we will soon.

 

In 2016, this will be a complete all or nothing with billions of Providers receivables not collectible for failing to take SB 863 seriously. This is more true with ancillary services such as urine drug screening.

 

Every day that a Providers fails to treat outstanding receivables (disputes) that SB 863 mandates in time limits,  as extreme urgency, is just monies rightfully due just disappearing, it is truly a serious matter that we will see the foolishness of not treating all receivables with a sense of urgency, by years end. 

 

One of the most, I do not know the correct word, so let's try self defeating statements I hear often, is when a company tells me they have 10, 20 or 30 million in Providers accounts outstanding  and insurance companies will not pay, and yet they have not done one IBR or proper second review or an appeal to an IMR decision, those monies are essentially gone.

The second most defeating thing I hear which has a million dollar price tag, is the inability or desire to master SB 863, or not take the default time limits with any sense of urgency, believing tricks and scams work, that I can find the word for, just plain stupidity.

by: www.workcompliens.com

 http://workcompliens.com/9-open-Web-Tox.html

 

Pasted from <https://www.linkedin.com/pulse/clinical-laboratories-urine-drug-screening-payments-work-boggan-jd?published=u>

 

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Urine Drug Screen Billing Codes 2015

Wednesday, August 26, 2015

11:18 AM

Essentially we have two general  types of testing, those for drug abuse, i.e. employment, legal etc., and then we have that for pain management, injured workers' etc. Then we have clinical laboratories and also the dip stick testing, which are very different.

 

In the in past several years the reimbursement for these test has gone up and down to the point that California has bundled all tests under G0431 at approximately $119.95 or less, regardless of whether it was a $10 cup test or a complex clinical  laboratory. 

 

The medical necessary of these test, with an increase in dangerous drugs being prescribed and the rise in deaths of overdoes in prescription  drugs, testing is essential.

Now as a medical Provider, one wants to know, not  only know that the patient is taking the prescribed  medication but in what amounts, to ensue that further assessment of medical treatment is accurate based on how one is responding to the medication prescribed, therefore the qualitative (if drug present) testing that a dip stick cup offers, would be insufficient. So, we have several questions, first, why have Providers not made the distinction , to warrant different reimbursements in the past and how does the new 2015 Medicare coding effect that.

 

Now, for the past, prior to 2014, basically  documentation and correct assertion of arguments, was a part of the down turn of reimbursement and or inconsistency.

 

However now for 2014 and 2015 while Medicare is trying to come up with a better plan, they have  put forth new reimbursement  codes. But once again the issue is, is a Provider only limited to qualitative  testing and are all bundled under G0431, unless drug confirmation is necessary.

 

Whenever, I do an analysis for something, that others may have a differing opinion, my state of mind is, could I make a valid argument in front of a judge and get a positive decision  that what I am asserting is correctly based on the law and facts that are provided. Then I keep working it until I can overcome all other interpretations by others, and this I did with the 2015 billing codes for urine drug screen.

 

The billing code put out by Medicare clearly shows three things, one not all qualitative testing is bundled under G0431, as they state which ones are, they state which codes are to be used for quantitative testing, and some codes used for either qualitative of quantitative testing.  As the paper they put out for some the codes they list qualitative or quantitative  and some qualitative (not all)  to use the G0431, then in a good number they do not list as either qualitative  or quantitative and have specific billing codes with values. It would be a hard sell, to believe, that they are specific on some and the ones that are not, we are to fill in the blanks, it does not read that way.

 

G0431 Bundled Qualitative

Not Bundled Under G0431 Qualitative or Quantitative

Billing Quantitative

Amobarbital, qualitative = G0431

 

Acetominophen  = G6039

Alkaloids, urine, quantitative (including quantitative codiene) =G6041

Amphetamine or methamphetamine, qualitative = G0431

 

Alcohol (ethanol); any specimen except breath (including ethyl alcohol) =G6040

Amphetamine or methamphetamine =G6042

 

 

Barbiturates, qualitative = G0431

 

Amitriptyline =G6030

Barbiturates, not elsewhere specified (including amobarbital) =G6043

Cocaine, qualitative = G0431

Benzodiazepines =G6031

Cocaine or metabolite = G6044

Codeine, qualitative =G0431

Carbon tetrachloride =82441

Dihydrocodeinone =G6045

Dihydrocodeinone, qualitative = G0431

Desipramine =G6032

Dihydromorphinone =G6046

 

Dihydromorphinone, qualitative = G0431

Dichloroethane = 82441

Dimethadione =G6048

Dimethadione, qualitative = G0431

Dichloromethane =82441

Flurazepam =G6051

Flurazepam, qualitative = G0431

Dihydrotestosterone = G6047

Methadone =G6053

Heroin = G0431

 

Doxepin =G6034

Phenothiazine (including chlorpromazine) =

G6057

Heroin screen = G0431

Drug confirmation, each procedure =G6058

 

Methodone, qualitative = G0431

Epiandrosterone = G6049

 

Phencyclidine (PCP), qualitative =G0431

Ethchlorvynol  = G6050

 

Phenothiazine, qualitative =G0431

Gold =G6035

 

 

Imipramine = G6036

 

 

Isopropyl alcohol = 84600

 

 

Methanol = 84600

 

 

Methsuximide =G6054

 

 

Nicotine = G6055

 

 

Nortriptyline =G6037

 

 

Opiate(s), drug and metabolites, each procedure (including nalorphine) =G6056

 

 

Salicylates (including aspirin) =G6038

 

 

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Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
URINE DRUG SCREEN    = Guidelines =
Elements Required in Documentation =Common
Errors= Authorized
CT SCAN = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
EMG/NCS   = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
CONSULT WITH PAIN MANAGEMENT =
Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHOLOGICAL EVALUATION =
Guidelines = Elements Required in
Documentation =Common Errors= Authorized
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: 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: 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: Left Knee Video
Arthroscopy, Medial Meniscectomy : Overturned
Program Authorization UR Denials Overturned
by IMR: Post operative land physical therapy 2 x 8
for the lumbar spine: Overturned
Program Authorization UR Denials Overturned
by IMR: Post operative land physical therapy 2 x 8
for the lumbar spine: Overturned
Program Files Medical Necessity RFA: Right
Elbow Cubital Tunnel Release: Overturned
Program Authorization UR Denials Overturned by
IMR: PROSPECTIVE REQUEST FOR 1
QUALITATIVE 12 PANEL URINE DRUG SCREEN
:Overturned
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Translated =Authorization/Medical Necessity:  =MTUS=ODG=ACOEM=Published Medical Journals=For Documentation
for Authorization in  The of Treatment Injured Workers  / Improved and Updated Weekly