1. ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care ® Oregon Medical Bill Reviewer Training Program Unit 4: Miscellaneous Guidelines

2. 2 Oregon Regulation Training – Miscellaneous Guidelines Overview Hi, Im here to guide you on a tour of Oregons Miscellaneous guidelines. These are rules and regulations not addressed under Professional or Hospital services. Part I: Introduction to Miscellaneous Guidelines Consultations Interpreter Services Reproduction (Copies) of Medical Records Clerical Administrative Fees Reports Medical/Legal Expenses Together, we will become more familiar with the unique aspects of these guidelines.

3. 3 Oregon Regulation Training – Miscellaneous Guidelines Miscellaneous Guidelines In this section you will find several guidelines that address rules outside the Professional and Hospital fee schedule. Missed Appointments No fee is payable for a missed appointment except a closing examination or an appointment arranged by the insurer or the department or for a Worker Requested Medical Examination. When the worker fails to appear without providing the provider with at least 24 hours notice, the medical provider must be recommended for payment at 50% of the examination or testing fee. A medical arbiter may also receive payment for a file review as determined by the director. Lets continue

4. 4 Oregon Regulation Training – Miscellaneous Guidelines Consultations Consultant Codes range from 99241 - 99275. An attending physician may submit a claim for consultants fee only when such service is requested by the carrier or self-insured employer. Missed individual appointments for consultations, without prior notification, will be compensated at 50% of the consultation fee. To correctly reimburse fees, use state specific code D0001.

5. 5 Oregon Regulation Training – Miscellaneous Guidelines Interpreter Services Interpretive services are billed using code D0004. Billing should include documentation of time spent. Interpretive Services are reimbursed at billed charge. For example, an interpreter could be used for a hearing impaired patient. Key 99080 for the review of an IME report prepared by another provider.

6. 6 Oregon Regulation Training – Miscellaneous Guidelines Medical/Legal Expenses Independent Medical Examinations (IME) Independent Medical Examination (IME), procedure code D0003 should be used for a report, file review or examination. If the insurer asks the attending physician to review the IME report and respond, the attending physician should bill for the time spent reviewing and responding using code D0019. Payment is recommended at billed charges with no PPO discount applied.

7. 7 Oregon Regulation Training – Miscellaneous Guidelines Medical/Legal Expenses Depositions Depositions provide evidence under oath outside the formal courtroom process. The fee for a deposition is billed using code D0002. This fee is billed at the medical providers hourly rate, which should include time for preparation, travel and deposition. Payment is based on the providers usual and customary hourly fee.

8. 8 Oregon Regulation Training – Miscellaneous Guidelines Medical/Legal Expenses Single Physicians Selected When a single physician is selected to review treatment, perform reasonable and appropriate tests, or examine the worker, the report submitted to the director is payable at an hourly rate up to a maximum of four hours for record review and examination. The physician should be recommended for payment for preparation and submission of the report. Billings for services by a single physician should be billed using code P0001 for the examination and code P0003 for the report.

9. 9 Oregon Regulation Training – Miscellaneous Guidelines Medical/Legal Expenses Physicians Selected to Serve on a Panel Physicians selected to serve on a panel of physicians should each receive payment based on an hourly rate up to a maximum of four hours for record review and panel examination. Each physician should bill for the record review and panel examination using code P0002. The panel member who prepares and submits the panel report should receive an additional payment using code P0003. In a more complex case requiring extensive review, physicians who are pre-authorized to bill for an additional fee may use code P0004.

10. 10 Oregon Regulation Training – Miscellaneous Guidelines Reports Key all report charges as billed using code 99080. Payment will be recommended at the usual and customary rate. Routine progress and final reports filed by the attending physician do not ordinarily command a fee.

11. 11 Oregon Regulation Training – Miscellaneous Guidelines Reports: Arbitration Reports The fee determination for arbitration is based on the complexity of the examination, the report requirements and the extent of the record review. The level of each category is determined by the director based on the individual complexities of each case as compared to the universe of claims in the medical arbiter process.

12. 12 Oregon Regulation Training – Miscellaneous Guidelines Reports: Arbitration Reports As determined by the director, A Level 1 exam generally involves a basic medical exam with no complicating factors. Key AR001. A Level 2 exam generally involves a moderately complex exam and may have complicating factors. Key AR002. A Level 3 exam generally involves a very complex exam and may have several complicating factors. Key AR003. A limited exam generally involves a newly accepted condition, or some other partial exam. Key AR004.

13. 13 Oregon Regulation Training – Miscellaneous Guidelines Reports: Arbitration Reports File Review As determined by the director: A Level 1 file review generally includes review of a limited record. Key AR021. A Level 2 file review generally includes review of an average record. Key AR022. A Level 3 file review generally includes review of a large record or disability evaluation without an exam. Key AR023.

14. 14 Oregon Regulation Training – Miscellaneous Guidelines Reports Arbitration Reports – File Review As determined by the director, A level 4 file review generally includes an extensive record. Level 4 File Review, key AR024 A level 5 file review generally includes an extensive record with unique factors. Level 5 File Review, key AR025

15. 15 Oregon Regulation Training – Miscellaneous Guidelines Reports The director will notify the medical arbiter and the insurer of the approved code for each component to establish the total fee for the medical arbiter review. If a worker fails to appear for a medical arbiter examination without giving each medical arbiter at least 48 hours notice, each medical arbiter should be paid at 50 percent of the examination or testing fee. For the missed appointment use code P0005. A medical arbiter may also receive payment for a file review as determined by the director.

16. 16 Oregon Regulation Training – Miscellaneous Guidelines Reports Narrative Reports Procedure code N0001 is used to bill for a brief narrative report by the Attending physician, including a summary of treatment to date and current status, and, if requested, brief answers to one to five specific questions related to the attending physicians current or proposed treatment. Procedure code N0002 is used to bill for a complete narrative report by the attending physician that may include past history, history of present illness, attending physicians treatment to date, current status, impairment, prognosis and medically stationary information.

17. 17 Oregon Regulation Training – Miscellaneous Guidelines Reports: Medical Arbiter The director will notify the medical arbiter and the insurer of the approved code for each component to establish the total fee for the medical arbiter review. If a worker fails to appear for a medical arbiter examination without giving each medical arbiter at least 48 hours notice, each medical arbiter should be paid at 50 percent of the examination or testing fee. A medical arbiter may also receive payment for a file review as determined by the director.

18. 18 Oregon Regulation Training – Miscellaneous Guidelines Reports: Supplemental Medical Arbiter If the director determines that a supplemental medical arbiter report is necessary to clarify information or address additional issues, an additional report fee may be established. The fee is based on the complexity of the supplemental report. For limited reports, key code AR031. For complex reports, key code AR032. Should an advance of costs be necessary for the worker to attend a medical arbiter exam, a request for advancement should be made in sufficient time to ensure a timely appearance. After receiving a request, the insurer must advance the costs in a manner sufficient to enable the worker to appear on time for the exam. If the insurer believes the request is unreasonable, the insurer should contact the director in writing. If the director agrees the request is unreasonable, the insurer may decline to advance the costs. Otherwise, the advance must be made timely as required in this subsection.

19. 19 Oregon Regulation Training – Miscellaneous Guidelines Review of Records When a medical provider is asked to prepare a report, or review records or reports prepared by another medical provider, insurance carrier or their representative, the medical provider should bill for their report or review of the records using CPT code 99080. The billing should include the actual time spent reviewing records or reports. This service should be reimbursed as a "By Report" procedure.

20. 20 Oregon Regulation Training – Miscellaneous Guidelines Copies of Medical Records There are instances when a patients medical records, x-rays and other images need to be copied for review by a provider other than the original rendering physician. The system is automated to recommend payment for copies of medical records at a fee of $10.00 for the first page and $.50 per page thereafter. Key code R0001 in the Procedure field (type of service is defaulted to '1') Key one unit of service in the Units field for each page copied.

21. 21 Oregon Regulation Training – Miscellaneous Guidelines Services provided by multi-disciplinary programs not otherwise described by CPT codes must be billed using Oregon specific codes. Treatment in a chronic pain management program, physical rehabilitation program, work hardening program, or a substance abuse program should not be paid unless the program is accredited for that purpose by the CARF or the JCAHO. Oregon Specific Multidisciplinary Service Codes

22. 22 Oregon Regulation Training – Miscellaneous Guidelines Oregon Specific Codes, Other Services Physical Capacity Evaluations (PCE) Physical capacity evaluations come in two levels. No fee is payable for the completion of a physical capacity evaluation form where no tests were performed. The PCE is classified in the following levels: 99196 - PCE Level I: First level evaluation – This is a limited evaluation measuring the functional performance of a specific body part. – This level requires not less than 45 minutes of claimant contact and includes the evaluation and report. – Additional 15-minute increments may be added if multiple body parts are reviewed and time exceeds 45 minutes. – Each additional 15 minutes is payable using code 99193 which includes the evaluation and report.

23. 23 Oregon Regulation Training – Miscellaneous Guidelines Oregon Specific Codes, Other Services Physical Capacity Evaluations (PCE) cont. 99197 - PCE Level II: Second level evaluation – This evaluation is requested by the insurer or attending physician to measure general functional capacity to perform work and provider other general evaluation information, including musculoskeletal evaluation. It may be used to establish Residual Functional Capacities for claim closure. – This evaluation requires not less than two hours of actual patient contact and includes the evaluation and report. – Additional 15-minute increments may be added to measure additional body parts, to establish endurance and to project tolerances. – Each additional 15 minutes is payable using code 99193, which includes the evaluation and report. Key as billed.

24. 24 Oregon Regulation Training – Miscellaneous Guidelines Oregon Specific Codes, Other Services Work Capacity Evaluation (WCE) 99198 is used to bill for a work capacity evaluation. – This evaluation places special emphasis on the ability to perform a specific job with the purpose of determining if the worker can return to work. – This level requires not less than 4 hours of actual patient contact and includes the evaluation and report. – Additional 15 minute increments (per additional body part) may be added to determine endurance (e.g. cardiovascular) or to project tolerances (e.g., repetitive motion). – Each additional 15 minutes should be payable using code 99193, which includes the evaluation and report. – D0030 (Insurer Consultation Time) Code D0030 is used to bill when an insurer requires a consultation with a medical provider.

25. 25 Oregon Regulation Training – Miscellaneous Guidelines Lodging and Meals Payment to workers for overnight travel charges to cover meals and commercial lodging are based on rates for the State of Oregon classified employees. The city in which the charges were incurred are indicated on a list for the Continental United States. If the city is not listed on the exceeding per diem rates table, then the user will manually pay the charge according to the standard rates. (See complete list is in the State Reference Guide) If the city is on the table, then the user will manually recommend payment for the charge according to the per diem rates on the listed table.

26. 26 Oregon Regulation Training – Miscellaneous Guidelines Lodging and Meals To apply the per diem rate, there are internal codes that must be used to manually price the rate structure. This is based on a standard rate of $77.00 for lodging and $46.00 for meals per day. Breakfast$11.50Type of service is 9 Key internal code BRK01 Lunch$11.50Type of service is 9 Key internal code LUN01 Dinner$23.00Type of service is 9 Key internal code DIN01 Lodging$77.00Type of service is 9 Key internal code LOD01 Room tax payable in addition to lodging. Key code 99070. Payment will be recommended at the billed charge.

27. 27 Oregon Regulation Training – Miscellaneous Guidelines Mileage All private vehicle mileage is paid at $.51 cents per mile, effective 1/11/2011. Internal code D0041 is keyed in the Procedure field using type of service 9. The number of miles are keyed in the Units field. One Unit equals one mile.

28. 28 Oregon Regulation Training – Miscellaneous Guidelines Summary Introduction to Miscellaneous Guidelines. Addresses rules outside the Professional & Medical fee schedule Information regarding Consultation Fees Interpreter Services and Medical/Legal Expenses Reports, Copies of Medical Records, Clerical Fees Lodging and Meals Mileage