Medical Fee Schedule: Evaluation
and Management Section 3

In Accordance with the N.C. Industrial Commission’s
Medical Fee Schedule & Subsequent Updates, 1996-2010

Bernadine Singh
Chief Medical Fee Examiner
N.C. Industrial Commission
E-mail: Bernadine.Singh@ic.nc.gov

Evaluation and Management Section 3

(NOTE: Please see Addendum at end of this document.)

General Information and Ground Rules

Items unique to the Evaluation and Management section are defined or identified here.

1.               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.)

2.               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

3.               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.

4.               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.

5.               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.

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

Addendum

• If a Rehabilitation Professional requests time to spend separate or additional time with a physician to discuss a patient’s case, the Medical Provider may use CPT Code 99361. If the Rehabilitation Professional 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 Rehabilitation Professional together.

• The Commission has suggested that the Medical Provider use the codes listed below for the following:

CPT Code 99455—Rating by the Treating Physician

CPT Code 99456—Rating by Other than the Treating Physician

CPT Code 99080—Narrative Report

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.

• 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:

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.