Mich. Admin. Code R. 418.10202 - Evaluation and management services
Rule 202.
(1) The
evaluation and management procedure codes from "Current Procedural Terminology,
CPT", as adopted by reference in
R 418.10107, shall be used on the
bill to describe office visits, hospital visits, and consultations. These
services are divided into subcategories of new patient and established patient
visits. The services are also classified according to complexity of the
services. For the purposes of workers' compensation, a treating practitioner,
for each new case or date of injury, shall use a new patient visit to describe
the initial visit. A treating physician may not use procedures 99450 or
99455-99456 to bill for services provided to an injured worker. When a
practitioner applies a hot or cold pack during the course of the office visit,
the carrier is not required to reimburse this as a separate charge.
(2) Minor medical and surgical supplies
routinely used by the practitioner or health care organization in the office
visit shall not be billed separately. The provider may bill separately for
supplies, or other services, over and above those usually incidental to the
evaluation and management service using appropriate CPT or HCPCS procedure
codes.
(3) When a specimen is
obtained and sent to an outside laboratory, the provider may add 99000 to the
bill to describe the handling/conveyance of the specimen. The carrier shall
reimburse $5.00 for this service in addition to the evaluation and management
service.
(4) Appropriate procedures
from "Current Procedural Terminology, CPT" or the HCPCS Level II codebook, as
adopted by reference in
R 418.10107, may be billed in
addition to the evaluation and management service. If an office visit is
performed outside of the provider's normal business hours, the provider may
bill the add on procedure code, 99050, describing an office visit performed
after hours or on Sundays or holidays and shall be reimbursed $12.00 in
addition to the evaluation and management. The carrier shall only reimburse the
miscellaneous add-on office procedures when the services are performed outside
of the provider's normal hours of business.
(5) A procedure that is normally part of an
examination or evaluation shall not be unbundled and billed independently.
Range of motion shall not be reimbursed as a separate procedure in addition to
the evaluation and management service unless the procedure is medically
necessary and appropriate for the injured worker's condition and
diagnosis.
(6) The maximum
allowable payment for the evaluation and management service shall be determined
by multiplying the relative value unit, RVU, assigned to the procedure code,
times the conversion factor listed in the reimbursement section of these
rules.
(7) The level of an office
visit or other outpatient visit for the evaluation and management of a patient
is not guaranteed and may change from session to session. The level of service
shall be consistent with the type of presenting complaint and supported by
documentation in the record.
(8)
When a provider bills for an evaluation and management service, a separate
drugadministration charge shall not be reimbursed by the carrier, since this is
considered a bundled service inclusive with the visit. The drug administration
charges may be billed and paid when the evaluation and management service is
not performed and billed for a date of service. The provider shall bill the
medication separate and be paid pursuant to the reimbursement provisions of
these rules. The provider shall use the NDC or national drug code for the
specific drug and either 99070, the unlisted drug and supply code or the
specific J-code listed in HCPCS to describe the medication
administered.
(9) When a provider
administers a vaccine during an evaluation and management service, both the
vaccine and the administration of the vaccine are billed as separate service in
addition to the evaluation and management visit according to language in CPT.
Both the administration of the vaccine and the vaccine shall be reimbursed
pursuant to the reimbursement provisions of these rules in addition to the
visit.
(10) Procedure code 76140,
x-ray consultation, shall not be paid to the provider in addition to the
evaluation and management service, to review x-rays taken elsewhere. The
carrier shall not pay for review of an x-ray by a practitioner other than the
radiologist providing the written report or the practitioner performing the
complete radiology procedure.
Notes
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