Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › EVALUATION AND MANAGEMENT › Section 20-2-I - DEFINITIONS AND RULES

Current through June 25, 2024
Definitions and rules pertaining to E/M services are as
				  follows:
A.
DOCUMENTATION MUST
				BE PATIENT SPECIFIC, PERTAIN DIRECTLY TO THE CURRENT VISIT AND SUPPORT THE
				EVALUATION AND MANAGEMENT SERVICES PROVIDED FOR THE INJURED WORKER. INFORMATION
				COPIED DIRECTLY FROM PRIOR RECORDS WITHOUT CHANGE IS NOT CONSIDERED CURRENT NOR
				COUNTED.
B.
Consultations.
CPT defines a consultation as "a type of evaluation
				and management service provided at the request of another physician or
				appropriate source to either recommend care for a specific condition or problem
				or to determine whether to accept responsibility for ongoing management of the
				patient's entire care or for the care of a specific condition or problem."
				(This includes referrals for a second opinion.) Consultations are reimbursable
				only to physicians with the appropriate specialty for the services provided.
In order to qualify as a consultation the following criteria
				  must be met:
* The verbal or written request for a consult must be
				  documented in the patient's medical record;
* The consultant's opinion and any services ordered or
				  performed must be documented by the consulting physician in the patient's
				  medical record; and
* The consulting physician must provide a written report to
				  the requesting physician or other appropriate source.
A payer/employer may request a second opinion examination or
				  evaluation for the purpose of evaluating temporary or permanent disability or
				  medical treatment being rendered, as provided in MCA §71 -3-15(1) (Rev.
				  2000). This examination is considered a confirmatory consultation. The
				  confirmatory consultation is billed using the appropriate level and
				  site-specific consultation codes 99241-99245 for office or other outpatient
				  consultations and 99251-99255 for inpatient consultations, with modifier 32
				  appended to indicate a mandated service.
Evaluation and management consultation services will continue
				  to be reported with CPT codes 99241-99245 for outpatient consultation services
				  and codes 99251-99255 for inpatient consultation services. The rules and
				  guidelines regarding the definition, documentation, and reporting of
				  consultation services as contained in CPT will apply unless superseded by these
				  guidelines. Consultation services will be reimbursed at the lesser of the Fee
				  Schedule maximum allowable reimbursment (MAR) or the billed amount.
C.
Referral.
Subject
				to the definition of "consultation" provided in this Fee Schedule, a referral
				is the transfer of the total or specific care of a patient from one physician
				to another and does not constitute a consultation. (Initial evaluations and
				subsequent services are designated as listed in the Evaluation and Management
				section).
D.
New and
				Established Patient Service.
Several code subcategories in the
				Evaluation and Management section are based on the patient's status as new or
				established. The new versus established patient guidelines also clarify the
				situation in which a physician is on call or covering for another physician. In
				this instance, classify the patient encounter the same as if it were for the
				physician who is unavailable.
*
New Patient.
A new patient is one who has
				  not received any professional services from the physician, or another physician
				  of the same specialty who belongs to the same group practice, for this same
				  injury or within the past three years.
*
Established Patient.
An established
				  patient is a patient who has been treated for the same injury by any physician,
				  of the same specialty, who belongs to the same group practice.
E.
E/M Service
				Components.
The first three components of history, examination, and
				medical decision making are the keys to selecting the correct level of E/M
				codes, and all three components must be met or exceeded in the documentation of
				an initial evaluation or consultation. However, in established, subsequent, and
				follow-up categories, only two of the three must be met or exceeded for a given
				code.
1. The history component is categorized
				by four levels:
a.
Problem
				Focused
. Chief complaint; brief history of present illness or problem.
b.
Expanded Problem
				Focused
. Chief complaint; brief history of present illness;
				problem-pertinent system review.
c.
Detailed
. Chief
				complaint; extended history of present illness; problem-pertinent system review
				extended to include a review of a limited number of additional systems;
				pertinent past, family medical and/or social history directly related to the
				patient's problems.
d.
Comprehensive
. Chief complaint; extended history of present
				illness; review of systems that is directly related to the problem(s)
				identified in the history of the present illness, plus a review of all
				additional body systems; complete past, family, and social history.