NORTH CAROLINA INDUSTRIAL COMMISSION

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MEDICAL FEE SCHEDULE

Section 3: Evaluation and Management

Note: Please see the ADDENDUM at the end of this document.


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Classification of Evaluation and Management (E/M) Services

The E/M section is divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes. This classification is important because the nature of physician work varies by type of service, place of service, and the patient’s status.

The basic format of the levels of E/M services is the same for most categories. First, a unique code number is listed. Second, the place and/or type of service is specified, e.g., office consultation. Third, the content of the service is defined, e.g., comprehensive history and comprehensive examination. (See levels of E/M services following for details on the content of E/M services.) Fourth, the nature of the presenting problem(s) usually associated with a given level is described. Fifth, the time typically required to provide the service is specified. (A detailed discussion of time is included in this section.)

Definitions of Commonly Used Terms

Certain key words and phrases are used throughout the E/M section.The following definitions are intended to reduce the potential for differing interpretations and to increase the consistency of reporting by physicians in differing specialties.

New Patient

A new patient is one who is new to the physician or an established patient with a new industrial injury or condition. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury, or illness.

Established Patient

An established patient is a patient who has been seen previously for the same industrial injury or illness by the physician.

In the instance where a physician is on call for or covering for another physician, the patient’s encounter will be classified as it would have been by the physician who is not available.

No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

Referral

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 evaluation and subsequent services are designated as listed in E/M services.)

Concurrent Care

The provision of similar services, e.g., hospital visits to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required.

Counseling

A discussion with a patient and/or family concerning one or more of the following areas:

  • Diagnostic results, impressions, and/or recommended diagnostic studies

  • Prognosis

  • Risks and benefits of management (treatment) options

  • Instructions for management (treatment) and/or follow-up

  • Importance of compliance with chosen management (treatment) options

  • Risk factor reduction

  • Patient and family education

Unlisted Service

An E/M service may be provided that is not listed in this section of CPT. When reporting such a service, the appropriate “Unlisted” code may be used to indicate the service, identify it “By Report” as discussed in Item 4. The Unlisted Services and accompanying codes for the E/M section are as follows:

99429 Unlisted preventive medicine service
99499 Unlisted evaluation and management service

By Report

An unlisted service or one that is unusual, variable, or new may require a special report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Additional items which may be included are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and the follow-up care.

Modifiers

Listed services may be modified under certain circumstances. When applicable, the modifying circumstance against general guidelines should be identified by the addition of the appropriate modifier code, which is reported by a two-digit number placed after the usual procedure number from which it is separated by a hyphen.

Non-CPT procedure codes and modifiers have been included in this schedule to reflect the services of Health Care providers not addressed in CPT. These codes have been identified as “state specific codes” within the description of the service.

In some circumstances, CPT modifiers have been revised. In this fee schedule only two digit modifiers are to be used.

PLEASE REFER TO THE AMERICAN MEDICAL ASSOCIATION’S CPT MANUAL FOR MORE INFORMATION ON PROPER CODING FOR EVALUATION AND MANAGEMENT SERVICES.

Note: To purchase a complete copy of the American Medical Association’s Current Procedural Technology Codes, telephone
OptumInsight™ at (800) 464-3649, option 1, or go to http://www.optumcoding.com/ to order a CPT® code book online.
The NC Industrial Commission Medical Fees Section is managed by Bernadine Singh, Chief Medical Fee Examiner.
Please report any problems or errors directly to Bernadine.Singh@ic.nc.gov

This page was last updated 5 April 2013
ADDENDUM
Revision Effective March 1, 2001

REVISION IN THE REIMBURSEMENT METHODOLOGY FOR PHYSICIAN ASSISTANTS PERFORMING EVALUATION AND TREATMENT SERVICES IN AN OFFICE, CLINIC OR FACILITY SETTING

The North Carolina Industrial Commission will allow reimbursement of evaluation and treatment services performed by a physician assistant that are considered within the physician assistants’ scope of practice. These services will be reimbursed at the rate of one hundred percent (100%) of the fee schedule allowance. Reimbursement will be allowed regardless of whether a supervising physician is on site at the office, clinic or facility or other place of treatment.

  • If a Case Manager requests time to spend separate or additional time with a physician to discuss a patient’s case, the Medical Provider may use CPT Code 99358 (see June 23, 2011 NCIC Minutes for details). If the Case Manager accompanies the patient to see the physician and does not require separate consultation time, the physician should bill according to the CPT code that describes the service rendered and time spent with the patient and the Case Manager together.
  • The Commission has suggested that the Medical Provider use the codes listed below for the following:

    CPT Code 99455
    CPT Code 99456
    CPT Code 99080
    IME - Independent Medical Evaluation (Includes records review and report of findings)

    NOTE: Code for disability Rating changed to 99455 on July 28, 2000
  • The Medical Advisory Committee to the North Carolina Industrial Commission met on March 14, 1996 to review the contested cases. The Committee recommended at this meeting that the Commission set a new code and new fees for an independent medical evaluation, which involves a review of medical records.

    The Commission, in review of the Committee’s recommendation, and upon further discussion, has decided to adopt the following codes, to be used for all independent medical evaluations, effective March 1, 1996, and to set the following fees based upon time expended for review of medical records. If a physical examination is performed, additional CPT codes may be used.

    Code Time Fee
    IME 01 1 hour $100.00
    IME 02 2 hours $200.00
    IME 03 3 hours or more $400.00
  • Professional services, including emergency room physician charges, should be billed using the HCFA 1500.
Evaluation and Management Section of the NCIC Medical Fee Schedule Regarding Telephone Conferences Effective July 1, 2010

The following CPT codes are added to the Evaluation and Management Section of the NCIC Medical Fee Schedule:

CPT Code Allowance
99441 $45.00
99442 $60.00
99443 $75.00

The following procedures have been added to the North Carolina Industrial Commission Medical Fee Schedule and are identified by the American Medical Association’s Current Procedural Terminology (CPT). Codes are current with 2001 additions displayed.

CPT Code Allowance
99234 $170.06
99235 $233.43
99236 $283.67
99239 $119.55
99298 $202.22
99315 $86.63
99316 $105.73
99344 $204.20
99345 $243.43
99347 $64.34
99348 $94.41
99349 $138.17
99350 $198.86
99374 BR
99377 BR
99378 $117.60
99379 BR
99380 BR
99435 $163.57
99436 $162.87

ABBREVIATIONS: BR = by report (i.e., report is needed to establish fee); CPT = Current Procedural Terminology; FUD = follow-up days (i.e., number of days in global period); PC (26) = professional component; and TC (27) = technical component.

Please note that some codes have a different reimbursement depending on whether the service is rendered in the physician’s office or in a hospital or facility setting. Companies who submit bills electronically through the State Information Processing Center will need to use the following modifiers for these codes:

OF = Performed in physician office; FA = Performed in facility.

CPT Codes Added 2002

CPT Code Total Fee
99289 BR
99290 BR

CPT only Copyright ©2004 American Medical Association. All Rights Reserved.


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