Proper OMFS charges for PR4 eval & report (California) (Cali

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Proper OMFS charges for PR4 eval & report (California) (Cali

Postby occdoc on Mon Apr 01, 2013 3:33 pm

Hello, Can anyone help

if we are the PTP and we are completing a PR4 on an injured worker, outlining Impariment, apportionment, futuremedical etc. can we use the ML fee schedule as a med-legal evaluation. Reg 9785 (a)(1) and (a)(4). The primary treating physician is “primarily responsible for managing the care of the employee” and among his reporting duties is making determinations on medical issues necessary to determine the employee’s eligibility for compensation including permanent and stationary status.

in that regard a defense WC atty stated to us: If you’re addressing causation, whole person impairment, apportionment, and future medical, and it is going to prove or disprove a disputed fact, then it sounds med/legal to me.

That said, I wouldn’t be surprised to find out there’s a regulation on that topic.
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Re: Proper OMFS charges for PR4 eval & report (California) (Cali

Postby suekarp on Tue Apr 02, 2013 6:50 am

I normally see PR-4s billed out as a 99080 OMFS code. Page one is a higher reimbursement than the remaining pages of the PR-4. The last time that I looked, the RV for page one is 6.5 and the remainder of the pages have RV of 4.0.
I hope this helps.
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Re: Proper OMFS charges for PR4 eval & report (California) (Cali

Postby occdoc on Tue Apr 09, 2013 1:52 pm

Thank you Suekarp,

But the 99080 per page x4 could not possibly cover the time it took to complete a PR4 in whole. would you opine that billing be done ala carte for the elements of the P&S process or use the ML fee schedule as the PTP addressing issues required as part of LC 9785.

Ala cart rational expanded upon.

Office visit...say 99214
Spending extra time explaining to the worker what the PR4 is, P&S , future medical care and all related questions... Extended OV 99354
Range of Motions and Grip strength using dual inclinometer 98851-52, 95852 etc
then you go to your desk and spend the next hour reviewing the records of the specialist on the case, the MRI, CT and related Operative reports and you look thru the AMA 5th edition to figure out whats what...say 60 at 99358
Then the 99080 per page as your outlined....this equals the charges for your work related to the PR4

Or

So you determine that you are the PTP, there is not QME / AME pending and you are pursuant to 9785 preparing a permanent and stationary report (PR4 format) addressing causation, impairment, apportionment, work status and future medical needs and you bill ML 102-104

Any thoughts, much appreciated.

Interestingly I have seen other PTP say the patient is P&S or MMI and a QME evaluation should be scheduled. Obviously turfing the whole PR4 report process.
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Re: Proper OMFS charges for PR4 eval & report (California) (Cali

Postby suekarp on Wed Apr 10, 2013 6:18 am

The charges that I outlined are for doing the PR-4 itself. If you do an exam, bill for it at the proper level of service. If you spend extra time reviewing records, document, and bill for it. If it is necessary to conduct extensive measurements, I believe that there is even a code for that.

I hope this helps.
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Re: Proper OMFS charges for PR4 eval & report (California) (Cali

Postby jonbrissman on Fri Apr 12, 2013 5:48 pm

in that regard a defense WC atty stated to us: If you’re addressing causation, whole person impairment, apportionment, and future medical, and it is going to prove or disprove a disputed fact, then it sounds med/legal to me.


The defense attorney missed two necessary elements for a medical-legal evaluation:
1. It must be requested by a party. The physician cannot decide on his/her own to produce a medical-legal report.
2. Advance notice of the medical-legal appointment must be given to all parties (Reg. 10430).

The defense attorney might want to review Reg. 10606, reporting requirements for treating physicians, and compare it to what he said. The regulation does not mention "prove or disprove a disputed fact" but that speaks to how the report will be used, not the content of the report.

You're on the right track with billing using CPT 99214 or 99215, 99354, 99358, 95851, 95852, and 99080, as appropriate, plus x-rays for a final treating physician's evaluation. The report must review and discuss any diagnostic tests which are billed concurrently. Also, mention any other physician's reports or conclusions being incorporated and provide interpreter information if one was used. Include the LC Sect. 4628 disclosures (which are meant for medical-legal reports and technically overkill but harmless within a PTP's report).

JCB
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