Presentation on theme: "California Medical Bill Reviewer Re-Certification"— Presentation transcript:
1California Medical Bill Reviewer Re-Certification Unit 2: Official MedicalFee ScheduleModule 8: Medicine
2OverviewWe’ll start by discussing some general guidelines, types of services in the medicine section, and different types of neurology and neuromuscular services common on workers’ comp bills...Hi! In this module, you will learn about different types of services in the medicine section of the OMFS.Medicine GuidelinesNeurology and Neuromuscular ServicesElectromyography (EMG)Nerve Conduction Studies (NCS)Medicine GuidelinesNeurology and Neuromuscular ServicesElectromyography (EMG)Nerve Conduction Studies (NCS)PsychiatryOphthalmology
3In the OMFS, the medicine section ranges from 90700-99199. Medicine GuidelinesUnlike other sections of the OMFS, the medicine section of the OMFS is comprised of several different types of services, procedures, and tests.DialysisOphthalmologyIn the OMFS, the medicine section ranges fromEar, Nose, & ThroatPsychiatry
4Medicine services include: Medicine GuidelinesIn fact, the medicine section is extensive and diverse in the types of services it includes.Medicine services include:PsychiatryDialysisOphthalmologyOtorhinolaryngologyNon-invasive Vascular Diagnostic StudiesPulmonary ServicesAllergy & Clinical ImmunologyNeurology and Neuromuscular ServicesCentral Nervous System Assessments/TestsChemotherapy AdministrationDermatological Procedures
5Neurology and Neuromuscular Services Medicine GuidelinesSome of these services are more common on workers’ compensation bills than others. We will be discussing a subset of those services, which include:PsychiatryNeurology and Neuromuscular ServicesOphthalmology
6Neurology and Neuromuscular Services Neurology and Neuromuscular services pertain to the diagnosis and treatment of illnesses or injuries that affect the nervous system, the musculoskeletal system, and how they work synergistically.Neurology and Neuromuscular services include procedures such as:Sleep studiesElectroencephalogramsMuscle testingElectromyographiesNerve conduction studiesDo you remember what these two terms mean?Right! Graphical recordings of the electrical activity of the brain and muscles, respectively.
7Neurology and Neuromuscular Services Two of the most common types of procedures that you will become familiar with are the:ElectromyographyNerve Conduction StudyLet’s take a look…
8ElectromyographyYou might recall from your study of medical terminology that an electromyography (EMG) tests the electrical potential, or electrical activity, of muscles.In other words, an electromyography assesses whether the patient has nerve or muscle damage.An electromyography can be used to diagnose disorders such as carpal tunnel syndrome.
9ElectromyographyElectromyography codes range from CPT to CPT 95875, and are specific to the number of extremities and/or different body areas.For Example:95860: One extremity and related paraspinal area95861: Two extremities and related paraspinal area95864: Four extremities and related paraspinal area95868: Cranial nerve supplied muscles, bilateral95869: Limited study of specific muscles (e.g. thoracic spinal muscles)
10Nerve Conduction Studies Similar to electromyography, nerve conduction studies evaluate electrical signaling of the motor and sensory nerves in the body.In general, nerveconduction studies areused to evaluate symptoms such as numbness, tingling, burning, or weakness in the extremities.Nerve conduction studies can be used to diagnose disorders such as:Peripheral neuropathyCarpal tunnel syndromeUlnar neuropathyGuillian-Barré syndrome
11Nerve Conduction Studies Nerve conduction studies consist of four separate components.Different components of a nerve conduction study can be billed for testing different types of nerves.Nerve conduction study components are:For example, there are three different nerves within the upper extremity that can be subject to motor or sensory testing. Other types of nerves are only tested with one component of the study.Motor NCSSensory NCSF-wave studyH-reflex study
12Nerve Conduction Studies The nerves are broken down into four major areas:RadialUpper ExtremityUlnarTibialMedianPeronealLower ExtremitySuralCervicalFemoralBackThoracicPlantarLumbarHeadCoccyxFacial
13Nerve Conduction Studies Upper ExtremityRadialUlnarMedianNerve conduction testing may be charged for all three nerves within the upper extremity.Each of these nerves can be subject to Motor or Sensory testing.Under no circumstance should more than six nerve conduction studies be allowed per arm.
14Nerve Conduction Studies Nerve conduction testing may be charged for:Tibial: Usually only the motor component is testedCommon PeronealSural: Sensory component onlyFemoralLower ExtremityTibialPeronealSuralFemoralPlantarHowever, nerve conduction studies can only be billed per nerve, not per segment of a single nerve. You will learn later how providers often bill for segments of nerves incorrectly.Occasionally, a test may be performed on both the medial and lateral plantar branch of the peroneal nerve.
15Nerve Conduction Studies HeadFacialWhen facial nerves are tested, only one nerve on each side of the face should be billed.Both motor and sensory components can be tested for a total not to exceed four studies.
16Nerve Conduction Studies The most commonly performed procedure codes billed for nerve conduction studies are:Common NCS Procedure Codes:Just like other types of services, providers often bill for nerve conduction studies incorrectly.CPT 95900: Nerve conduction, MotorCPT 95903: Nerve conduction, Motor with F-WaveCPT 95904: Nerve conduction, SensoryCPT 95934: H Reflex Study (Left or Right, up to 2)Let’s take a look…
17Nerve Conduction Studies There are several things to be aware of when you process bills with charges for nerve conduction studies.Things to Remember:Why might this be?The fee schedule states very clearly that testing is done per nerve. However, providers often mistakenly bill per segment.Recall that CPT includes both motor and F-wave components of the nerve conduction study.Always verify the number of nerves tested. Many providers tend to bill for multiple segments on the same nerve.CPT should be denied if providers bill a CPT on the same nerve.
18PsychiatryPsychiatry focuses on the diagnosis, treatment, and prevention of emotional and behavioral disorders.While the psychiatry section of the CPT has been updated, California’s OMFS contains an outdated version of this section.It is important to note providers often bill from the CPT, but will be paid according to OMFS.This makes processing and reviewing bills difficult, as many codes have been added & descriptions have been revised.
19Psychiatric Consultations Psychiatric consultations differ from psychiatric treatment.Like other types of consultations, psychiatric consultations are only billed with standard E & M consultation codes , and do not involve treatment.Psychiatric consultations include:Examination of the patient.Communication with the family and primary physician.Preparation of a report.
20Psychiatric Treatments Psychiatric treatments are billed with psychiatric treatment codes.The key psychiatric treatment codes for individual psychotherapy are CPTCPT is a BR code because it is “time unspecified.”Psychiatrists are trained early to keep track of the time spent with each patient. Therefore, there is no need to pay a BR code.This code should always be denied and sent back to the provider for a specific time period identification.
21Psychiatric Treatments In addition to individual psychotherapy codes, there are family psychotherapy codes.These codes are not specified by time. Therefore, they are paid once per session.That’s right! Check for documentation.If multiple units are billed, what should you do?If more than one unit is billed, documentation is required to verify multiple sessions occurred on a single date of service.
22Psychiatric Treatments Individual and family psychiatric treatment codes also include medical evaluation and drug management services.Therefore, E & M visits and the drug management code, CPT 90862, are not allowed with these types of psychotherapy codes.
23Other Therapeutic Services In addition to psychiatric counseling, there are other types of therapeutic services.Other therapeutic services, which include:Electroconvulsive therapyNarcosynthesisHypnotherapy...may be billed with E & M services if significant, separately identifiable services are performed.
24Other Therapeutic Services Non-physician providers may bill for their services using medicine codes.Recall from your study of Physician’s Services, that non-physician providers include:Marriage counselorsFamily counselorsChild counselorsLicensed social workersLet’s take a look…
25Other Therapeutic Services Non-physician providers who bill CPT or CPT should use Modifier –88.However, there is no value assigned to this modifier.This tells you that the modifier is informational only.What does this tell you?-88This modifier is used when psychiatric codes are billed by family or marriage counselors, as well as clinical social workers.
26OphthalmologyOphthalmology is the medical service focused on the diagnosis, treatment, and prevention of disorders of the eye.The OMFS specifically states Special Ophthalmological Services are above and beyond the services included in the general exam and may be billed separately.There has been confusion over whether ophthalmologists can bill for special services if they also charge for a general exam.
27In this case, an additional E & M charge would be non-reimbursable. OphthalmologyGeneral eye exams include a medical diagnostic evaluation.What does this tell you?Correct!In this case, an additional E & M charge would be non-reimbursable.Specifically, an additional E & M charge from CPT would be inappropriate.
28OphthalmologyMost ophthalmologic procedures are considered bilateral. However, in some instances only a single eye is examined or treated.Under these circumstances, Modifier –52 is added to the appropriate CPT code.-52 Reduced ServicesThis modifier is used if a service has been reduced from the standard procedure.
29Summary Psychiatry Reimbursement Guidelines Medicine: Services and GuidelinesPsychiatry Reimbursement GuidelinesReimbursement of Other Therapeutic ServicesElectromyography Reimbursement GuidelinesNerve Conduction Study Reimbursement GuidelinesReimbursement of Ophthamological Services