Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 2 - MEDICINE › Section R. 418.10202 - Evaluation and management services

Current through Vol. 24-12, July 15, 2024
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.