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Acupuncture The guidelines note that the amount of acupuncture to produce functional Improvement
is 3 to 6 treatments....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Acute Rehab, Inpatient Physical/Occupational Therapy MTUS page 42 states that
Detoxification is defined as withdrawing a person from a specific psychoactive substance and it does not
imply a diagnosis of addiction, abuse or misuse....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Aquatic Therapy Chronic Pain Treatment Guidelines state that aquatic therapy (up to 10 sessions) is
recommended as an optional form of exercise therapy where available as an alternative to land-based
physical therapy. They go on to state that it is specifically recommended whenever reduced weight
bearing is desirable, for example extreme obesity....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Arthroscopic decompression (acromioplasty) (shoulder)
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Arthroscopy rotator cuff repair MTUS/ACOEM Guidelines state that rotator cuff repair is
indicated for significant tears that impair activities by causing weakness of arm elevation or rotation,
particularly acutely in younger workers.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Autonomic Nervous System Evaluation: Per the ODG, autonomic nervous system evaluation is not
generally recommended as a diagnostic test for CRPS. The ODG recommends assessment of clinical
findings as the most useful method of establishing the  diagnosis....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Bilateral lumbar facet neurotomy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Biofeedback According to the MTUS treatment guidelines for  biofeedback it is not Recommended as a
stand -alone treatment but is recommended as an Option within a cognitive behavioral therapy program to
facilitate exercise Therapy and returned to activity.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Bone growth simulator The Official Disability Guidelines indicate that bone growth stimulators are under
study and may be considered medically necessary as an adjunct to lumbar spinal  fusion surgery for
patients with any of the following risk factors for failed fusion: ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Botox injection Criteria for a botulinum  toxin (Botox) for prevention of chronic migraine headaches
include a diagnosis of chronic migraine headache  with  frequent headaches lasting  4 hours a day or  
longer,  And not responsive to at least three prior first -line migraine headache prophylaxis medications.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Carpal Tunnel Release Official Disability Guidelines were also referenced for more specific
recommendations. According to the Official Disability Guidelines regarding surgery for carpal tunnel
syndrome, Recommended after An accurate diagnosis of  moderate or severe  Surgery is not generally
initially indicated  for mild CTS unless symptoms persist after conservative treatment.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Chiropractic care According to Chronic Pain Medical Treatment Guidelines, MTUS (Effective July 18,
2009) Page 58, Manual therapy & manipulation: Recommended for chronic pain if caused by
musculoskeletal conditions. Manual Therapy is widely used in the treatment of musculoskeletal pain....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Cognitive behavioral therapy ODG Cognitive Behavioral Therapy (CBT) guidelines for chronic pain
recommend screening for patients with risk factors for delayed recovery, including fear avoidance
beliefs.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Complete Blood Count Complete Blood Count . Per the cited guidelines The presence of infection is
defined by 2 classic findings of inflammation (redness, warmth, swelling, tenderness or pain) or
purulence.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Consultation to Psychologist According to the MTUS psychological evaluations are generally accepted,
well-established diagnostic procedures not only with selective use in pain problems,....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Consultation with Neurology "The occupational health practitioner may refer to other specialists if a
diagnosis is .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Consultation with Pain Management Specialist "The occupational health practitioner may refer to other
specialists if ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Continuous-flow Cryotherapy MTUS/ACOEM  is silent on the issue of cryotherapy. According to
ODG, .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

CT scan Per ODG guidelines,.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Diagnostic injections.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Diagnostic facet blocks The ODG notes: Criteria for  the use ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Diagnostic nerve blocks....MTUS is silent on selective nerve root blocks. Under ODG, ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

DVT Prophylaxis unit...
•         Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Elbow ulnar nerve decompression and medial epidonylectomy CA MTUS/ACOEM is silent on the issue
of surgery for cubital tunnel syndrome. According to the ODG, ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Electronic psych testing          The Industrial Guidelines do not specifically address Electronic psych
testing: but does  address ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

EMG .Decision rationale: Electromyography (EMG) is a diagnostic test used to measure ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

EMG/NCV (Electromyogram/Nerve Conductive Velocity) ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

EMGs (electromyography)...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Epidural Injections.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Extracorporeal shock wave therapy The official disability guidelines recommends extracorporal shock
wave therapy for certain conditions ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

FRP Multidisciplinary evaluation to assess candidacy for FRP....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Functional Capacity Evaluation ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Functional RESTORATION AFTERCARE PROGRAM...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

H Wave ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Hand/Wrist Home Exercise Rehab Kit....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Hernia repair....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Home health aide....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

•        Home health physical therapy ODG Guidelines consider home health services as medically
necessary When .....
o        Criteria (Clinical  documentation)....
o        Common Errors:...
o        Billing Codes and Payment Issues....

Hypnotherapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Implantable Drug-Delivery Systems ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Inpatient detox....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Inpatient Detoxification Program Detoxification is defined as .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Interdisciplinary pain programs.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Interferential (IF) unit Interferential current works in a similar fashion as TENS, but at a substantially
higher frequency (4000-4200 Hz....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Knee arthroscopy with meniscectomy “......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Knee brace Official Disability Guidelines' criteria for custom fabricated k...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Life Skills and cognitive coach The California MTUS, ACOEM, and ODG all do not reference a life
skills.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

LINT (Localized intense neurostimulation therapy)....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

LSO Brace " ODG Guidelines regarding lumbar supports states "not recommended for prevention,
however, .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Lumbar spinal fusion....
•        Criteria: (ODG),....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Manipulation under anesthesia....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Medial Branch Block ODG as cited below: "Criteria for the use ....medial branch blocks; ODG
recommends ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Medication Management ODG cites that "....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Medication Management / Pharmacological Management
•        Criteria: ODG states .....
o        Criteria (Clinical  documentation)....
o        Common Errors:...
o        Billing Codes and Payment Issues....

Metal artifact reduction ....     
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Knee and Leg...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

ODG states that a brain MRI is recommended for the following indications:...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Headaches:....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Elbow....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Forearm,....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Wrist and Hand.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Neck and Upper Back.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI of the abdomen,....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

•        MRI Pelvic / Hip.....
o        Criteria (Clinical  documentation)....
o        Common Errors:...
o        Billing Codes and Payment Issues....

MRI Shoulder Injury The criteria for MRI of the shoulder include....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Spine / Low Back ODG guidelines Low Back Chapter MRI Topic, state... ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRIs (magnetic resonance imaging)....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Nerve Conduction Studies....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Nerve Conduction Velocity (NCV).....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Chapter, Proton Pump Inhibitors (PPIs)......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Occupational therapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

ODG (Compounds General) Topical analgesics.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Open reduction and internal fixation of left.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Fibula under fluoroscopy a rod, plate and/or nails) is then ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

OPIOIDS ON -GOING MANAGEMENT....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Orthovisc injections .ODG Guidelines,.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Hyaluronic acid injections is Recommended.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Outpatient Detox
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Management Consult.......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Psychology Evaluation.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Pump....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....
Patient education classes.....

•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pens Therapy  Percutaneous electrical nerve stimulation ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Physical therapy....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Physical therapy with massage.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-op lab work ODG used.As per cited guidelines for Preoperative lab testing,......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-op medical clearance......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-op studies chest x-ray.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-Operative EKG.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....
Proton pump inhibitor....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Proton Therapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

PRP (platelet rich plasma) injection     
•               Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psych Evaluation to determine candidacy for entry and participation into the Functional Restoration
Program......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psyche testing SC-90-R.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psychiatric Evaluation......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psychological Treatment incorporated.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psychology referral.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pulmonary Function Test......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

ODG notes recommendations for Spirometric testing in the workplace where spirometry is employed in
the primary, secondary, and tertiary prevention ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Range of motion test ODG states regarding Range of Motion, "Not recommended as primary criteria, ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Referral to a nutritionist....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Rotator cuff repair .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Sacroiliac joint injection Guidelines recommend sacroiliac blocks as an option.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Spinal cord stimulation General Criteria for a spinal cord stimulator trial....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Static progressive stretch (SPS) therapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

TENS unit transcutaneous electrical nerve stimulation Criteria:......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

TFESI under Fluoroscope....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Transportation.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Trigger point injections.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

U/S Guided Corticosteroid Injection......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Unna boot.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Urine toxicology.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

.Video Fluoroscopic Evaluation of the Shoulders (with motion).....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Viscosupplementation injections.....
•         Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Voltage-Actuated Sensory Nerve Conduction Threshold of Lumbar Spine...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Weight loss program...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work conditioning...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....
Work Conditioning Program physical therapy....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work Harding Screening "......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

X-Rays Guidelines state.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Yoga Sessions .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....
Drug Class        Generic Name        Brand Name
Antidepressants        Amitriptyline        Elavil®
Antidepressants        Bupropion        Wellbutrin®
Antidepressants        Citalopram        Celexa
Antidepressants        Duloxetine        Cymbalta®
Antidepressants        Escitalopram        Lexapro®
Antidepressants        Fluoxetine        Prozac®
Antidepressants        Fluvoxamine         Luvox
Antidepressants        Milnacipran        Savella/Ixel®
Antidepressants        Paroxetine         Paxil
Antidepressants        Sertraline        Zoloft®
Antidepressants        Venlafaxine        Effexor®
Antidepressants        Venlafaxine ER        Effexor XR®
                
Antidiabetics        Acarbose        Precose
Antidiabetics        Exenatide        Byetta
                
Anti-epilepsy drugs (AEDs)        Gabapentin        Neurontin®, Gabarone™
Anti-epilepsy drugs (AEDs)        Gabapentin ER        Gralise
Anti-epilepsy drugs (AEDs)        Gabapentin ER        Horizant
Anti-epilepsy drugs (AEDs)        Lacosamide        Vimpat®
Anti-epilepsy drugs (AEDs)        Lamotrigine        Lamictal®
Anti-epilepsy drugs (AEDs)        Levetiracetam        Keppra®
Anti-epilepsy drugs (AEDs)        Oxcarbazepine        Trileptal®
Anti-epilepsy drugs (AEDs)        Phenytoin        Dilantin®
Anti-epilepsy drugs (AEDs)        Pregabalin        Lyrica®
Anti-epilepsy drugs (AEDs)        Tiagabine        Gabitril®
Anti-epilepsy drugs (AEDs)        Topiramate        Topamax®
Anti-epilepsy drugs (AEDs)        Zonisamide        Zonegran®
Anti-epilepsy drugs (AEDs)         Carbamazepine        Tegretol®
                
Antihypertensives        Aliskiren        Tekturna
Antihypertensives        Amlodipine        Norvasc
Antihypertensives        Atenolol        Tenormin
Antihypertensives        Benazepril        Lotensin
Antihypertensives        Captopril        Capoten
Antihypertensives        Clonidine        Catapres
Antihypertensives        Doxazosin        Cardura
Antihypertensives        Enalapril        Vasotec
Antihypertensives        Hydralazine        Apresoline
Antihypertensives        Hydrochlorothiazide        HCTZ
Antihypertensives        Lisinopril        Zestril
Antihypertensives        Losartan        Cozaar
Antihypertensives        Metoprolol        Lopressor
Antihypertensives        Minoxidil        Loniten
Antihypertensives        Nadolol        Corgard
Antihypertensives        Nicardipine        Cardene
Antihypertensives        Nifedipine        Procardia
Antihypertensives        Olmesartan        Benicar
Antihypertensives        Prazosin        Minipress
Antihypertensives        Propranolol        Inderal
Antihypertensives        Ramipril        Altace
Antihypertensives        Spironolactone        Aldactone
Antihypertensives        Terazosin        Hytrin
Antihypertensives        Valsartan        Diovan
                
Anti-infectives        Amoxicillin        Amoxil
Anti-infectives        Amoxicillin-Clavulanate        Augmentin
Anti-infectives        Azithromycin        Zithromax
Anti-infectives        Cefadroxil        Duricef
Anti-infectives        Cefdinir        Omnicef
Anti-infectives        Cefprozil        Cefzil
Anti-infectives        Cefuroxime        Ceftin
Anti-infectives        Cephalexin        Keflex
Anti-infectives        Ciprofloxacin        Cipro
Anti-infectives        Clarithromycin        Biaxin
Anti-infectives        Clindamycin        Cleocin
Anti-infectives        Dicloxacillin        Dynapen
Anti-infectives        Doxycycline        Vibramycin, Doryx
Anti-infectives        Levofloxacin        Levaquin
Anti-infectives        Linezolid        Zyvox
Anti-infectives        Metronidazole        Flagyl
Anti-infectives        Minocycline        Minocin, Dynacin
Anti-infectives        Moxifloxacin        Avelox
Anti-infectives        Penicillin        Veetids
Anti-infectives        Sulfamethoxazole-Trimethoprim        Bactrim, Septra
                
Asthma medications        Albuterol inhalation        Proventil®/ Ventolin®
Asthma medications        Albuterol oral tablet        Albuterol
Asthma medications        Albuterol/Ipratropium        Combivent®
Asthma medications        Beclomethasone        Qvar®
Asthma medications        Budesonide inhalation        Pulmicort®
Asthma medications        Ciclesonide        Alvesco®
Asthma medications        Cromolyn        Cromolyn
Asthma medications        Fluticasone inhalation        Flovent®
Asthma medications        Formoterol        Foradil®
Asthma medications        Formoterol/Budesonide        Symbicort®
Asthma medications        Formoterol/Mometasone        Dulera®
Asthma medications        Indacaterol        Arcapta®
Asthma medications        Ipratropium        Atrovent®
Asthma medications        Levalbuterol        Xopenex®
Asthma medications        Mometasone inhalation        Asmanex®
Asthma medications        Montelukast        Singulair®
Asthma medications        Omalizumab        Xolair®
Asthma medications        Pirbuterol        Maxair®
Asthma medications        Salmeterol        Serevent®
Asthma medications        Salmeterol/Fluticasone        Advair®
Asthma medications        Theophylline        Slo-Bid®
Asthma medications        Zafirlukast        Accolate®
Asthma medications        Zileuton        Zyflo®
                
Atypical antipsychotics        Aripiprazole        Abilify
Atypical antipsychotics        Quetiapine        Seroquel
Atypical antipsychotics        Olanzapine        Zyprexa
Atypical antipsychotics        Risperidone        Risperdal
                
Benzodiazepines        Alprazolam        Xanax
Benzodiazepines        Chlordiazepoxide        Librium
Benzodiazepines        Clonazepam        Klonopin
Benzodiazepines        Clorazepate        
Benzodiazepines        Diazepam        Valium
Benzodiazepines        Estazolam        ProSom
Benzodiazepines        Flurazepam        Dalmane
Benzodiazepines        Lorazepam        Ativan
Benzodiazepines        Midazolam        Versed
Benzodiazepines        Oxazepam        Serax
Benzodiazepines        Quazepam        Doral
Benzodiazepines        Temazepam        Restoril
Benzodiazepines        Triazolam        Halcion
                
Bisphosphonates        Alendronate        Fosamax®
Bisphosphonates        Etidronate        Didronel®
Bisphosphonates        Ibandronate        Boniva®
Bisphosphonates        Risedronate        Actonel®
Bisphosphonates        Risedronate        Atelvia®
                
Botulinum toxin        Botulinum toxin        Botox®
Botulinum toxin        Botulinum toxin        Dysport
Botulinum toxin        Botulinum toxin        Myobloc®
Botulinum toxin        Botulinum toxin        Xeomin
                
Cannabinoids        Marijuana/dronabinol        Marinol®
Cannabinoids        Nabilone        Cesamet®
Cannabinoids        Tetrahydrocannabinol        THC/ dronabinol
                
Central adrenergic agonists        Clonidine, intrathecal        Duraclon®
                
Dopamine agonists        Carbidopa/Levodopa        Sinemet®
Dopamine agonists        Pramipexole        Mirapex®
Dopamine agonists        Ropinirole        Requip®
Dopamine agonists/precursors        Amantadine        Symmetrel
                
Gout medications        Colchicine        Colchicine
                
Muscle relaxants        Baclofen        Lioresal®
Muscle relaxants        Benzodiazepines        N/A
Muscle relaxants        Carisoprodol        Soma®
Muscle relaxants        Chlorzoxazone        Parafon Forte®, Paraflex®, Relax™DS,
Remular S™
Muscle relaxants        Chlorzoxazone        Lorzone®
Muscle relaxants        Cyclobenzaprine        Flexeril®, Fexmid™
Muscle relaxants        Cyclobenzaprine ER        Amrix®
Muscle relaxants        Dantrolene        Dantrium®
Muscle relaxants        Diazepam        Valium
Muscle relaxants        Meprobamate        Miltown
Muscle relaxants        Metaxalone        Skelaxin®
Muscle relaxants        Methocarbamol        Robaxin®, Relaxin™
Muscle relaxants        Orphenadrine        Norflex®, Banflex®, Antiflex™, Mio-Rel™,
Orphenate
Muscle relaxants        Tizanidine        Zanaflex®
                
Muscle relaxants (Antispasmodics)        Carisoprodol        Soma®
Muscle relaxants (Antispasmodics)        Chlorzoxazone        Parafon Forte®, Paraflex®,
Relax™DS,Remular S™
Muscle relaxants (Antispasmodics)        Cyclobenzaprine        Flexeril®, Fexmid™
Muscle relaxants (Antispasmodics)        Metaxalone        Skelaxin®
Muscle relaxants (Antispasmodics)        Methocarbamol        Robaxin®, Relaxin™
Muscle relaxants (Antispasmodics)        Orphenadrine        Norflex®, Banflex®,
Antiflex™, Mio-Rel™, Orphenate
Muscle relaxants (Antispasticity drugs)        Baclofen        Lioresal®
Muscle relaxants (Antispasticity drugs)        Dantrolene        Dantrium®
Muscle relaxants (Antispasticity/ Antispasmodics)        Benzodiazepines        N/A
Muscle relaxants (Antispasticity/ Antispasmodics)        Tizanidine        Zanaflex®
                
Nonprescription analgesics        Acetaminophen        Tylenol®
Nonprescription analgesics        Aspirin        Bayer®
Nonprescription analgesics        Ibuprofen        Advil®
Nonprescription analgesics        Naproxen        Aleve®
                
NSAIDs         Diclofenac        Voltaren®
NSAIDs         Diclofenac        Zorvolex
NSAIDs         Diclofenac Epolamine        Flector patch
NSAIDs         Diclofenac Potassium        Cataflam®
NSAIDs         Diclofenac Potassium        Zipsor
NSAIDs         Diclofenac Sodium        Voltaren®
NSAIDs         Diclofenac Sodium ER        Voltaren-XR®
NSAIDs         Diclofenac Sodium Gel        Voltaren® Gel
NSAIDs         Diclofenac Sodium Injection        Dyloject
NSAIDs         Diclofenac Sodium topical        Pennsaid®
NSAIDs         Diclofenac/ misoprostol        Arthrotec®
NSAIDs         Diflunisal        Dolobid®
NSAIDs         Etodolac        Lodine®
NSAIDs         Etodolac ER        Lodine XL®
NSAIDs         Fenoprofen        Nalfon®
NSAIDs         Flurbiprofen        Ansaid®
NSAIDs         Ibuprofen        Advil®
NSAIDs         Ibuprofen        Motrin®
NSAIDs         Indomethacin        Indocin®
NSAIDs         Indomethacin        Tivorbex
NSAIDs         Indomethacin ER        Indocin SR®
NSAIDs         Ketoprofen        Ketoprofen
NSAIDs         Ketoprofen ER        Ketoprofen ER
NSAIDs         Ketorolac        Toradol®
NSAIDs         Ketorolac injection        Toradol®
NSAIDs         Ketorolac nasal spray        Sprix
NSAIDs         Mefenamic Acid        Ponstel®
NSAIDs         Meloxicam        Mobic®
NSAIDs         Nabumetone        Relafen®
NSAIDs         Naproxen        Aleve®
NSAIDs         Naproxen        Anaprox DS®
NSAIDs         Naproxen        Anaprox®
NSAIDs         Naproxen        Naprosyn®
NSAIDs         Naproxen ER        EC-Naprosyn®
NSAIDs         Naproxen ER        Naprelan®
NSAIDs         Oxaprozin        Daypro®
NSAIDs         Piroxicam        Feldene®
NSAIDs         Sulindac        Clinoril®
NSAIDs         Tolmetin        Tolectin DS
NSAIDs         Tolmetin        Tolectin®
NSAIDs (non-steroidal anti-inflammatory drugs)        Celecoxib        Celebrex®
                
Opioids        Buprenorphine inj.        Buprenex®
Opioids        Buprenorphine inj.        Buprenex®
Opioids        Buprenorphine SL tab        Bupren.
             
Opioids        Buprenorphine transdermal        Butrans™
Opioids        Buprenorphine/Naloxone buccal film        Bunavail®
             
Opioids        Buprenorphine/Naloxone SL film        Suboxone®
             
Opioids        Buprenorphine/Naloxone SL tab        Bupren/Nalox
             
Opioids        Buprenorphine/Naloxone SL tab        Zubsolv
             
Opioids        Butalbital combos (barbiturates)        Fioricet®
Opioids        Codeine        Codeine
Opioids        Codeine/acetamin.        Tylenol #3
Opioids        Fentanyl buccal        Fentora®
Opioids        Fentanyl buccal film        Onsolis™
Opioids        Fentanyl lollipop        Actiq®
Opioids        Fentanyl nasal spray        Lazanda
Opioids        Fentanyl sublingual spray        Subsys®
Opioids        Fentanyl transdermal        Duragesic®
Opioids        Fentanyl transmucosal        Abstral
Opioids        Hydrocodone ER        Hysingla
Opioids        Hydrocodone ER        Zohydro
Opioids        Hydrocodone/acetamin.        Lortab®
Opioids        Hydrocodone/acetamin.        Vicodin®
Opioids        Hydrocodone/ibuprofen        Vicoprofen®
Opioids        Hydromorphone        Dilaudid®
Opioids        Hydromorphone ER        Exalgo
Opioids        Levorphanol        Levo-Dromoran®
Opioids        Meperidine        Demerol®
Opioids        Methadone        Methadose®
Opioids        Morphine        Morphine
Opioids        Morphine ER        Avinza®
Opioids        Morphine ER        Kadian®
Opioids        Morphine ER        MS-Contin
Opioids        Morphine ER / Naltrexone        Embeda
Opioids        Naloxone        Evzio®
Opioids        Naloxone        Narcan®
Opioids        Oxycodone        Oxecta
Opioids        Oxycodone        OxyIR®
Opioids        Oxycodone ER        OxyContin®
Opioids        Oxycodone ER/acetamin.        Xartemis XR
Opioids        Oxycodone ER/Naloxone        Targiniq ER®
Opioids        Oxycodone/acetaminophen         Percocet®
Opioids        Oxycodone/aspirin        Percodan®
Opioids        Oxycodone/ibuprofen        Combunox
Opioids        Oxymorphone        Opana®
Opioids        Oxymorphone ER        Opana ER®
Opioids        Pentazocine lactate        Talwin
Opioids        Pentazocine/Naloxone        Talwin NX
Opioids        Propoxyphene hcl        Darvon®
Opioids        Propoxyphene napsylate        Darvon-N®
Opioids        Propoxyphene/acetamin.        Darvocet®
Opioids        Tapentadol        Nucynta™
Opioids        Tramadol        Ultram®
Opioids        Tramadol ER        ConZip
Opioids        Tramadol ER        Ultram ER®
Opioids        Tramadol/Acetaminophen        Ultracet®
Opioids        Ziconotide (morphine pump)        Prialt®
                
Oral corticosteroids        Methylprednisolone        Medrol
Oral corticosteroids        Prednisone        Prednisone
                
PPI (Proton Pump Inhibitor)        Dexlansoprazole         Dexilant®
PPI (Proton Pump Inhibitor)        Esomeprazole        Nexium®
PPI (Proton Pump Inhibitor)        Esomeprazole/Naproxen        Vimovo
PPI (Proton Pump Inhibitor)        Famotidine (H2 blocker)/ Ibuprofen        Duexis®
PPI (Proton Pump Inhibitor)        Lansoprazole        Prevacid®
PPI (Proton Pump Inhibitor)        Omeprazole        Prilosec®
PPI (Proton Pump Inhibitor)        Pantoprazole        Protonix®
PPI (Proton Pump Inhibitor)        Rabeprazole        Aciphex®
                
Prostaglandins        Misoprostol        Cytotec®
                
Sedative-hypnotics        Diphenhydramine        Benadryl
Sedative-hypnotics        Eszopicolone        Lunesta™
Sedative-hypnotics        Promethazine        Phenergan
Sedative-hypnotics        Ramelteon        Rozerem™
Sedative-hypnotics        Trazodone        Desyrel
Sedative-hypnotics        Zaleplon        Sonata®
Sedative-hypnotics        Zolpidem        Ambien®
Sedative-hypnotics        Zolpidem        Edluar SL
Sedative-hypnotics        Zolpidem ER        Ambien CR
                
Stimulants (adjunctive pain medication)        Armodafinil        Nuvigil
Stimulants (adjunctive pain medication)        Modafinil        Provigil®
Stimulants (adjunctive pain medication)        Sodium Oxybate        Xyrem
                
Topical analgesics        Capsaicin, topical        Qutenza
Topical analgesics        Diclofenac Sodium Gel        Voltaren® Gel
Topical analgesics        Dimethylsulfoxide        DMSO
Topical analgesics        Ketamine, topical        Ketamine
Topical analgesics        Lidocaine, topical        Lidoderm®
Topical analgesics        Salicylate topicals        Ben-Gay
                
Tumor necrosis factor (TNF) modifiers        Adalimumab        Humira®
Tumor necrosis factor (TNF) modifiers        Etanercept        Enbrel®
Tumor necrosis factor (TNF) modifiers        Infliximab        Remicade®
Billing Code         Insurance Objection
0232T        Claims Administrator denied service indicating: “Value of the services
is included in the value of another service performed on the same day.”


0232T        Claims Administrator denied code with rationale “The charge exceeds
the Official Medical  Fee Schedule allowance”

0232T-RT
     Claims Administrator denied code with rationale “ Included in another billed
procedure.”

0232T-RT and 0232T-LT
     Claims Administrator reimbursed both codes with rationale “The Official
Medical Fee Schedule does not list this code. An allowance has been made for a
comparable service.”

20680
     
20680        The Claims Administrator
denied service with the following rational: “Service not paid under
OPPS.

20680-RT
     The Claims Administrator denied service with the following rational: “OP
service status indicator Q. Q1
-Q3 payable only when not packaged or bundled w/other services billed on same
day”

24357-59 and 20610-59
     Claims Administrator denied codes with indication “no separate payment was
made because the value
of the service is included within the value of another service performed on the
same day”

27425, 29877-59, 29874-59, 29875
-59, and 20610-59
     Claims Administrator reimbursed CPT code 29875 in the amount $191.11 and
denied all other services billed.
29822-59,29826
-59
     
29824        •The Claims Administrator denied charges indicating: •Initial EOR:
“We cannot review without the necessary documentation...”Final EOR: “Medical
documentation does not support the services rendered”

29848-LT, 64718
-LT, 26055-LT, and 20550-59LT
     Claims Administrator denied all codes with rationale “diagnosis was invalid for
the date(s) of service reported”
29881-51
     Claims Administrator denied code indicating on the Explanation of Review
“No separate payment was made because the value of the service is included
within the value of another service performed on the same date of service.”
29882        Claims Administrator denied code indicating “Allowance is based on
Utilization Review pre-authorization”
63047
-
59
-
51
     
63650 and 63650
-59
     EOR indicates DWC Payment Reduction G1:“The charge exceeds the Official
Medical Fee Scheduled Allowance.”
63661 x 3        Claims administrator denied codes indicating on the Explanation of
Review “No separate payment was made because the value of the service is
included within the value of another service performed on the same day””
64483-        LT
     Claims Administrator denied codes indicating on the Explanation of Review
“Service/item included in the value of other services per CCI edits. Related service
could be on a separate bill .” EORs submitted show only two codes billed, 64483
and 72275.

64493 and 64495        
64493 and 64495        
64510        Claims Administrator denied service indicating on the Explanation of
Review “ This service appears to be unrelated to the patients diagnosis”

64520        Claims Administrator denied code with rationale “revenue codes and
other packaged procedures are not separately
Reimbursable and are to be packaged into other services when billed on an
outpatient basis”

64718-59
     Claims Administrator denied code indicating “no separate payment was made
because the value of the service is included within the value of another service
performed on the same day”

72070 and
72110
     Claims administrator denied codes indicating on the Explanation of Review
“The charge was denied as the report/documentation does not indicate that the
procedure was performed.”
72275-26-59
     Claims Administrator denied code indicating on the Explanation of Review
“The appended modifier code is not appropriate with the service billed”

73721        The Claims Administrator denied service as unauthorized.
76942        The Claims Administrator denied reimbursement for 76942 stating:
“Incidental to Procedure,” and  “rarely, if ever, performed.”
90792,
Psychiatric diagnostic
evaluation
     Claims Administrator denied code indicating “The charge was denied as the
report/documentation does not indicate that the service was performed

90833        
90837        Claims Administrator denied code indicating on the Explanation of
Review “CPT code submitted is based on service time and documentation does
not support the time spent on this procedure”

90837        Claims Administrator denied code indicating on the Explanation of
Review “CPT code submitted is based on service time and documentation does
not support the time spent on this procedure”


90837 x 4 units
     Claims Administrator denied 90837 service stating: “Per CCI Edits, the value
of this procedure is included in the value of the comprehensive procedure.”
90880
     
95886 and 95913        Claims Administrator denied reimbursement indicating
“charge is denied as the service was not
Authorized during the Utilization Review process
.

95913        Claims Administrator denied code with indication “The testing results
are needed in order to review this charge”

95913 and 95937        EOR’s indicate service 95913 down-coded to reflect
“contract rate.”

95937        Claims Administrator denied code indicating on the Explanation of
Review “This service appears to be unrelated to the patient’s diagnosis”
95937        Claims Administrator denied code 95937 indicating on the Explanation
of Review “code 95937 is reported once per each nerve. Code 95937 cannot be
reported for bilateral (modifier 50) studies.
96101 and WC007        Claims Administrator denied 96101 with rationale “Per
CCI edits, the value of this procedure is included in the value of the
comprehensive procedure”
96101-59 and 99354
     The Claims Administrator denied charges as “included” in the value of other
services performed on the same day.

96101-59, 96102, 90899, and WC007
     The Claims Administrator denied codes with rationale


96118-59
     Claims Administrator denied code indicating on the Explanation of Review
“CCI: Standards of Medical/Surgical Practice” and “included within the value of
another service performed on the same day”
97110-GP
     The Claims Administrator’s reimbursement rational indicates: “Contract Rate.”
97113-59        Claims administrator denied code indicating on the 1st Explanation
of Review “ please provide chart notes or office notes so we can proceed with the
correct payment
97140        Service denied by Claims Administrator as “Mutually exclusive
procedures.”
97530 x 4 Units
     
97530-59
     Claims Administrator denied codes and indicated on the Explanation of Review
“Per CCI edits, the value of this procedure is included in the value of the mutually
exclusive procedure.”

97530-59 and 97750-59
     97530 and 97750 are both time based codes each 15 minutes.
•Claims Administrator denied codes and indicated on the Explanation of Review
“Per CCI edits, the value of this procedure is included in the value of the
comprehensive procedure.”

97545        The Claims Administrator denied reimbursement as “not reimbursable
under Medicare Hospital Outpatient Fee Schedule.”
97545
             The Claims Administrator denied reimbursement as “not reimbursable
under Medicare Hospital Outpatient Fee Schedule.”
97670-30-86
     •EOR’s reflect the following:
•1st EOR: 1) Pre-Authorization Required 2)Authorization Number Invalid or
Missing.
• 2nd EOR: 1) Reimbursement of $403.75 2) per Pre-Authorization and Labor
Code.
•01/04/2016Final EOR: 1) Pre-Authorization Required 2) Documentation Does
not support a
significant identifiable E&M Service 3) Per LC 5307.1

97750        EOR’s indicate charges “exceeded the scheduled allowance.”

97750        Claims administrator reimbursed $956.41 indicating on the Explanation
of Review “Pricing reductions due to MPN
97750 x 12        EOR does not indicate 97750 as unauthorized but does state “No
separate payment was made because the value of  The service is included within
the value of another service performed on the same day”

97750 x 32        
97799-86
     97799-86
     97799-86
     97799        
97799        Claims Administrator reimbursed $5131.95 indicating on the
Explanation of Review “Approved by Utilization Review”

97799
Sample: Progress Notes for FRP        Claims Administrator reimbursed $5131.95
indicating on the Explanation of Review “Approved by
Utilization Review”

97799 86        
97799 86
Initial Interdisciplinary Evaluation        Reduction not stated
97799 -86
60% PPO         Claims Administrator denied FRP services stating, “The Official
Medical Fee Schedule does not list code. Multiple Procedure Payment Rule
Applied”
97799-86
     Claims Administrator reimbursed $2538.00 indicating on the Explanation of
Review “Reimbursement for physical medicine procedures, modalities, including
Chiropractic Manipulation and acupuncture codes are limited to 60 minutes per
visit without prior authorization pursuant to Physical Medicine rule 1?”
empathy
97799-86
     
97799-86
Functional Restoration Evaluation        The Claims Administrator’s reimbursement
rational indicates the following: “This charge was adjusted to comply with the rate
and rules of the contract indicated.”

97799-86
Initial Evaluation -Functional Restoration Evaluation        
97799-86
Initial Functional Restoration Evaluation        
97799-86
Initial Functional Restoration Program        The Claims Administrator’s
reimbursement rational indicates the following: “This charge was adjusted to
comply with the rate and rules of the contract indicated.”
97799-86        Initial Evaluation - Functional Restoration Evaluation
97799-86
Functional Restoration
Evaluation

     EOR indicate The Claims Administrator’s reimbursement was based on
“Physical Medicine” and
“negotiated rate.”

97799-86
     Claims Administrator denied FRP services stating, “The billing has exceeded
the fee schedule guidelines for payment of physical therapy or physical medicine
treatment.”
97799-86
     Claims Administrator denial rational: “Documentation to substantiate this
charge was not submitted or is insufficient to accurately review this charge.”
97799-86
     Claims Administrator denial rational: “This is an unlisted procedure. Please
resubmit the bill with a more descriptive code or documentation.”

97799-86
Functional Restoration Evaluation        EOR indicate services denied as “not
authorized by utilization and review
97799-86
     
97799-86
     The Claims Administrator denied reimbursement with the following rational:
“The defendant disputes whether the treatment is reasonable or necessary
97799-86
     The Claims Administrator denied reimbursement as “not medically necessary.”
97799-86
     EOR indicate services denied as “not authorized by utilization and review.”
97799-86
One Day Multidisciplinary
Evaluation
     The Claims Administrator denied reimbursement as “not medically necessary
97799-86
     
97799-86
Initial
Functional
Restoration
Evaluation
services
     
97799-86
     The Claims Administrator denied reimbursement with the following rational:
“The defendant disputes whether the treatment is reasonable or necessary
97799-86
     •The Claims Administrator denied reimbursement as “unlisted procedure.”

97799-86
     •The Claims Administrator denied reimbursement as “Preauthorization is
required for this service or procedure.”

97799-86
Initial valuation”  regarding
a “Functional Restoration Program
     Claims Administrator reimbursement rational -as reflected on EOR as follows:
“Charges reduced in accordance with base allowance per the applicable fee
schedule.”

97799-86
Initial
Interdisciplinary
Evaluation

     
97799-86
     
97799-86
     
97799-86
     The Claims Administrator’s reimbursement rational indicates “pre-negotiated
agreement” and “contract” indicated.

97799-86 (27 units)
     
97799-86.        The Claims Administrator denied reimbursement as “unlisted
procedure.”

97799-86x 5
     Claims Administrator denied code for three dates of service indicating on the
Explanation of Review “Unlisted/BR svc not documented. Payment requires
documentation explaining the service. See OMFS instructions for Procedures
without Unit Values.”
97813, 97814, 97110


     
Claims Administrator denied codes with rationale “
•Many therapy services are time-based codes, i.e., multiple units may be billed for
a single procedure . The MPPR applies to the Practice Expense (“PE”) payment
when more than one unit or procedure is provided to the same patient on the same
day, i.e., the MPPR applies to multiple units as well as multiple procedures. Full
payment is made for the unit or procedure with the highest PE payment. Full
payment is made for the work and  malpractice components and 50 percent
payment is made for the PE for subsequent units and procedures, furnished to the
same patient on the same day

99199        •Initial, subsequent and final EOR’s reflect the Claims Administrator
denied reimbursement with the following rational: “Service has a relative value of
zero”


99199        Initial, subsequent and final EOR’s reflect the Claims Administrator
denied reimbursement  with the following rational: “Service has a relative value of
zero”
99204 and WC007        The Claims Administrator denied services in full due to
“absence of pre-certification.”

99204 and WC007        The Claims Administrator denied service in full stating,
“Claim Settled, no open medical treatment allowed
99204 and WC007-
30
     The Claims Administrator denied service as follows:
•99204 “included in the value of another service,”
•WC007 “report does not appear to be requested...”

99205
-
25
,
99354
     
99205        The Claims Administrator’s denied service as not authorized

99205        Claims Administrator denied code indicating not authorized

99205        •The Claims Administrator’s denied service as not authorized


99205-25
     The Claims Administrator’s denied service as not authorized
99214        The Claims Administrator denied reimbursement due to “billing E/M
codes is limited to physicians, physician assistants or nurse practitioners,
therefore this service is not reimbursed”

99214 and WC002        Letter to Provider from The Claims Administrator dated
7/31/2015 & 08/15/2015 denied services with the following rational: “The provider
was not cert5ified/eligible to be paid for this procedure/service on this date of
service.”
99214 and WC002        The Claims Administrator denied reimbursement due to
“Duplicate claim/service”

99214 and WC002        The Claims Administrator denied the service based on
unauthorized service.
99215 and WC002        The Claims Administrator’s denied reimbursement due to
unauthorized services
99215 and WC002        The Claims Administrator denied services as unauthorized.
99215 and WC002        The Claims Administrator denied services as
“unauthorized.”

99215 and WC002
     The Claims Administrator’s denied reimbursement due to unauthorized
services
99215, WC002, and J3490 x 2        Claims Administrator denied codes with
rationale not authorized.
99215-25
     Claims Administrator denied code with rationale “The visit or service billed,
occurred within the global surgical period and is not separately reimbursable”
99215-25, 62370, and 76942-26
     Claims Administrator denied services indicating on the Explanation of Review
“No separate payment was made because the value of the service is included
within the value of another service performed on the same day”

99215-25, WC002, G0434, 96101, and
99358 x 2
     Claims Administrator’s denial rationale “Services not provided or authorized
by designated (Network) Providers”

99354        •The Claims Administrator denied services based on documentation.

99354 and
99355
     
99354 and 99355        The Claims Administrator denied 99354 and 99355 due to
insufficient information to adjudicate claim.
99354 and 99355        The Claims Administrator denied services based on
documentation.
99354, 99355, 99358, and 99359
     •Claims Administrator denied service with the following rational:
•99354 & 99355: Report/documentation does not indicate service was performed.
•99358 & 99359 “No Separate payment was made because the value of the service
is included within the value of another service performed on the same day.”

99354, 99355, and 99359        Claims Administrator denied service with the
following rational:
•99354 & 99355: “Documentation provided does not justify payment for a
Prolonged Evaluation and Management service.”
•99359 “No Separate payment was made because the value of the service is
included within the value of another service performed on the same day.”

99358        Services Bundled
99358 and 99080        •Claims Administrator denied codes indicating on the
Explanation of Review “service has a relative value of zero and therefore no
payment is due  ”

99358 and 99359        Claims Administrator denied 99358 and 99359 with the
following rational: “According to the Fee Schedule, this charge is not covered.”
99358 and 99359        Claims Administrator denied codes indicating on the
Explanation of Review “According to the Official Medical Fee Schedule, this
service has a relative value of zero”
99358 and 99359         •The Claims Administrator denied services indicating
“charge not covered per OMFS.”
•Opportunity to Dispute communicated to Claims Administrator on 02/29/2016 ,
response not yet received.

99358 and 99359        Provider seeking remuneration 99358 Prolonged Services
W/O face -to-face contact and add-on code 99359 each additional 30 minutes (list
separately).
•The Claims Administrator denied services indicating “This code is either not valid
or not available in the California Fee Schedule.”

99359        The Claims Administrator reimbursed 1 of 11 units indicating
“scheduled allowance.”
99359        The Claims Administrator reimbursed 1 of 11 units indicating “
scheduled allowance.”
99499
-
86
     
99499        Claims Administrator denied reimbursement with the following
rationales: “If a flat rate has been agreed upon for the Functional Restoration
Program, please provide a signed adjuster agreement”

99499
Functional Restoration Evaluation
     Claims Administrator denied reimbursement with the following rational: “The
Unlisted or BR service was not received or sufficiently identified or documented...”
99499        The Claims Administrator based $0.00 reimbursement on “negotiated
rate”.
99499-86
     SBR by Claims Administrator resulted in “duplicate claim” with upheld
recommended allowance of “$0.00,”
•Initial EOR indicated “documentation” required for reimbursement.

99499-86
     Claims Administrator postponed payment post documentation review.

Billing rules:
Arthroscopic synovectomy of the knee        
DRG 472        The Claims Administrator indicates Provider “paid correctly per
fee schedule and (Claims administrator) PPO contract. Additionally, the Claims
Administrator asserts the Provider has yet to contact (Claims Administrator)
regarding contractual payment allowance.
E1339-LL        Claims Administrator re-assigned E1399-LL (lease) to E0730 NU
(new it)indicating:



“Based on review services rendered to be best described by this code "E0730."

E1339-LL
Decision After Appeal Initial IBR Decision
     Provider submitted appeal of original denial of E1399 for no authorization to
the Workers’ Compensation Appeals Board.
E1339-LL
     Claims Administrator denied code indicating on the Explanation of Review
“not authorized”

E1339-LL
     Claims Administrator denied code
indicating on the Explanation of Review “not authorized
E1399-LL
     The Claims Administrator’s denial rational: “In order to review this charge we
will need a copy of the invoice
G0260        
G0260 and 20610        The Claims Administrator “$0.00” reimbursement for
G0260 and 20610 rationale based on “Payment for this charge is not recommended
per our Utilization Management Department” and “Denied per Adjuster”

G6041, G6045, G6046, and G6
056
     EORs indicate laboratory results reflecting Provider’s place of business is
required for  determination
and consideration of  reimbursement.

J7324-LT
     Claims Administrator reimbursed NDC with rationale “The charge exceeds the
Medi-Cal pharmacy fees for Workers’ Compensation prescriptions”
L0637        The Claims Administrator denied service with the following rational:  
“In order to review this charge, we will need a copy of the invoice, ” citing 5307.1
(e).
L1990        Claims Administrator denied reimbursement with the following rational:

This item is packaged or bundled into another basic service.”

L3908-RT-LT
and L1832-LT
     Claims Administrator denied codes indicating “Payment denied/reduced for
absence of precertification/ authorization.

L6034
(Rev Code 0274)
     
Ml Reports         
ML100        •ISSUE IN DISPUTE: Provider seeking remuneration for ML100
Missed Med-Legal

ML100        Claims Administrator denied billed code with indication “Medical
Legal missed appointment code used for communication purposes only”

ML101
-
93
-
95
     
ML101
-
92
     
ML101        Claims Administrator reimbursed $3403.13 from total billed amount
$6187.50 with rationale “excessive billing, and asserts that approximately 45% of
the 66 page report includes commentary outside Provider’s area of expertise
ML101
-
94
     Claims Administrator denied reimbursement based on “criteria.”

ML101        The Claims Administrator indicates ML101 units reduced based on
submitted report.

ML101-94, 96100
     EOR 11/19/2013 reflects reimbursement by Claims Administrator in the
amount of $168.24. Reimbursement rational: “Amounts billed above the payment
or the recommend allowances as shown, are hereby objected to as being in excess
of amounts authorized under Labor Code...”

ML101-95
     Claims Administrator denied services indicating: “Provider does not
participate in MPN.”

ML101-95
     Claims Administrator denied services indicating: “Payment denied/reduced for
absence of, or exceeded, pre-certification/authorization.”

ML101-95, ML104-95
     The Claims Administrator denied initial ML101-95 reimbursement with the
following rational:
•Please remit initial ML report.

ML102        The Claims Administrator based reimbursement on 99214,
Established Patient Evaluation and WC004
Primary Treating Physician Permanent and Stationary Report, as “more
appropriate.”

ML102-95-93
     Claims Administrator denied code indicating “the charge was denied as the
report/documentation does not indicate that the service was performed”

ML103-86
     Claims Administrator reimbursed ML 103 as 99205 indicating on the
Explanation of Review “The documentation does not support the level of service
billed. Reimbursement was made for a code that is supported by the
documentation submitted with the billing”

ML103-94
     Claims Administrator reimbursed $324.83 after changing ML 103 to 99215
and WC004.
ML104
-
93
     
ML104        
ML104        
ML104        
ML104
     The Claims Administrator denied ML104 for the following reasons:  
“Unauthorized.”
ML104        
ML104        Claims Administrator denied reimbursement with rationale “This
workers’ compensation claim has been denied”

ML104        Claims Administrator denied ML 104 with rationale “Claim is denied.
No payment will be made.”

ML104        Claims Administrator reimbursed ML 104 as ML 103 with rationale
“services rendered appear to be best described by this code”

ML104
-
95
     Claims administrator down coded ML 104 to ML 103 indicating on the
Explanation of Review “Billing greater than Medical Legal Allowance” and
“Qualified Medical Examiner”

ML104        Claims Administrator denied services with the following rational: “No
Reimbursement was  made for the E/M services as the documentation does not
support a separate significant identifiable E&M service performed with other
services provided. Plan Procedures not followed.”


ML104 and 96101        The Claims Administrator denied reimbursement pending
documentation
ML104 x 38        
ML104,
73110, 72110, 73562, 73030 and 72040
     Claims Administrator ML104 reimbursement rational: “FCE Not Requested,”
and “Not Authorized.”
ML104-86-92
     The Claims Administrator based reimbursement on “better defining service,”
99215 Established Patient Evaluation
ML104-86-92
(ML by PTP)         •The Claims Administrator based reimbursement on “better
defining service,” 99215 Established Patient Evaluation
ML104-92
     Claims Administrator denied reimbursement for services with the following
rational: “Documentation does not support the level of service billed.”
ML104-92
     
ML104-92 (ML by PTP Requited by Applicant)
     Claims Administrator reimbursed Down-coded the service to Evaluation and
Management  Code 99215, stablished Patient, and California Reporting Code
WC004,  Primary Treating  Physician's Permanent and. Stationary Report based
on the following rational: “The Official Medical Fee Schedule Does Not List This
Code. An Allowance has been made for a comparable service
ML104-94
     The Claims Administrator reimbursed ML 104-94 however,  down-coded total
units based on elements of report.
ML104-94
     Claims Administrator shows an allowance of $9125.00 on the Explanation of
Review  dated 6/17/2014 for ML 104 indicating “Recommended payment of this
procedure or
supply should be reimbursed only if pre-authorization has been obtained by the
Claims
Examiner
ML104-94
     Claims Administrator down coded ML 104 to ML 103 indicating "the
following are not considered factors or were not met: Record Review”

ML104-94
     The Claims Administrator denied services requesting re-submission with “ICD.
10” coding.

ML104-94-95        •The Claims Administrator down coded ML 104 to a ML 102
and reimbursed services $781.25 with the following rational: “the charge exceeds
the Official Medical Fee Schedule  allowance. The charge has been adjusted to the
scheduled allowance.” Claims Administrator
also disputing the timeliness of second bill review.

ML104-94-95
     The Claims Administrator
reimbursed $4,250.00 with
rationale “reasonable charges on this case would be 17 hours x 4 =68 units


ML104-95
     
The Claims Administrator down-coded the billed ML104-95 to ML103 with the
following explanation: “The documentation does not support the level of service
billed. Reimbursement was made for a code that is supported by the
documentation submitted with the billing.”
ML104-95
     The Claims Administrator denied service with the following rational: “The
Patient cannot be identified as having a claim against this Claims Administrator.”
ML104-95
     
ML104-95
     Claims Administrator reimbursed $62.50 of the billed total $2625.00 with
indication of  “the charge exceeds the Official Medical Fee Schedule Allowance.
The charge has been adjusted to the scheduled allowance

ML104-95
     Claims Administrator down coded ML 104 to ML 103 with rationale “Report
does not meet 4 or more complexity factors listed under ML 104 as required by
Title 8 CCR 9795”
ML104-95
     Claims Administrator reimbursed 27 units for a total of $1687.50 of the 99
units billed.

ML104-95
     The Claims Administrator reimbursed the Provider “$1,625.00” of  
“$3,812.50, ”indicating “Official Medical Fee Schedule” rational.
•EOR’s do not indicate ML104level of services down-coded or denied.

ML104-95
     Claims Administrator denied service with rationale “Alternative services were
available and should have been utilized

ML104-95
     Claims Administrator down coded ML 104 to a ML 103and reimbursed
Services $937.50 with the following rational: “the charge exceeds the Official
Medical Fee Schedule allowance. The charge has been adjusted to the scheduled
allowance
.

ML104-95
     Claims Administrator down coded ML 104 to a ML 103
And reimbursed services
$843.75 with the following rational: “documentation doesn’t support the level of
service
.

ML104-95
     The Claims Administrator denied ML104 indicating “Charge exceeds the
Official medical Fee Schedule allowance.”
ML104-95
     Claims Administrator reimbursed $7125.00 indicating “20 hours billed for
records review is a bit excessive”
and only reimbursed Provider for 14.5 hours.

ML104-95-25
     Claims Administrator denied service originally. A third EOR submitted by
Claims Administrator after the dispute had been filed, shows ML 104 processed
with a payment to be made to Provider in the amount of $4125.00
ML106        EOR indicate services denied to “insufficient information” required to
adjudicate claim.
ML106        Communication from the Claims Administrator dated November 2,
2015 requesting a reexamine of the injured worker as a Panel Qualified Medical
Examiner with a list of directives to submit in his report was submitted for this
review.
ML106
-
95
     
ML106-94
     Claims Administrator reimbursed Provider $2,968.75 and then re-cooped
funds for service.
ML106-95
     Claims Administrator reimbursed ML 106 and a separate 99080 which was
denied payment.

ML106-96        The Claims Administrator denied reimbursement pending
“authorization.”
NCD's 38779-0082-09, 63275
-9913-09, 51552
-1285-08
     Claims Administrator provided the following explanation for denial: “non
FDA approved agent, therefore is considered non reimbursable.”
Telephone call services (99371-
99373)        
WC002 and 99215        
WC002 and 99215        Claims Administrator denied codes indicating on the
Explanation of Review “Provider not authorized to bill for proc/svc”
WC004        The Claims Administrator denied the service with the following
rational: “This report does not fall under the guidelines of separately reimbursable
reports.”
WC004 and 99215
-17
     The Claims Administrator denied services as not authorized.
WC004 x 8 and 99499 x 8        
WC007         •The Claims Administrator denied service in full stating, “a charge
was made or a separate procedure that does not meet the criteria for separate
payment. See Physician ’s Fee Schedule Gen.”

WC007-30
     The Claims Administrator denied service with rationale “The visit or service
billed occurred within the global surgical period and is not separately
reimbursable.”
The Basics of Medical-Legal Evaluations
By Richard J Boggan JD /06062016



The below was taken from actual IBR (Independent Bill Review)
decision that are exact determination of when ML warranted and when
mistakes have cased MLs not to be paid properly, indication to overall
definition and application not found in plain reading of the ML
regulations.

Definitions of Article 5.6 Medical-Legal Expenses and Comprehensive
Medical-Legal Evaluations §9793 (h) "Medical-legal expense" means any
costs or expenses incurred by or on behalf of any party or parties, the
administrative director, or the appeals board for X-rays, laboratory fees,
other diagnostic tests, medical reports, medical records, medical
testimony, and as needed, interpreter's fees, for the purpose of proving
or disproving a contested claim. The cost of medical evaluations,
diagnostic tests, and interpreters is not a medical-legal expense unless it
is incidental to the production of a comprehensive medical-legal
evaluation report, follow-up medical-legal evaluation report, or a
supplemental medical-legal evaluation report and all of the following
conditions exist:  (1) The report is prepared by a physician, as defined
in Section 3209.3 of the Labor Code. (2) The report is obtained at the
request of a party or parties, the administrative director, or the appeals
board for the purpose of proving or disproving a contested claim and
addresses the disputed medical fact or facts specified by the party, or
parties or other person who requested the comprehensive medical-legal
evaluation report. Nothing in this paragraph shall be construed to
prohibit a physician from addressing additional related medical issues

Pursuant Section 9795: The fee for each evaluation is calculated by
multiplying the relative value by $12.50, and adding any amount
applicable because of the modifiers permitted under subdivision (d). The
fee for each medical-legal evaluation procedure includes reimbursement
for the history and physical examination, review of records, preparation
of a medical-legal report, including typing and transcription services, and
overhead expenses. The complexity of the evaluation is the dominant
factor determining the appropriate level of service under this section; the
times to perform procedures is expected to vary due to clinical
circumstances, and is therefore not the controlling factor in determining
the appropriate level of service.

ML Requested by Injured Worker
: “Provider, an Orthopedic Specialist, was requested by Legal Parties in
the matter of (Injured Worker)”        (This taken from an IBR decision
that awarded ML-104 illustrates that the injured worker can request the
PTP or QME to do a ML )

ML 100:  Missed Appointment for a Comprehensive or Follow-Up
Medical-Legal Evaluation. This code is designed for communication
purposes only. It does not imply that compensation is necessarily owed.

ML 101: Follow-up Medical-Legal Evaluation. Limited to a follow-up
medical-legal evaluation by a physician which occurs within nine months
of the date on which the prior medical-legal evaluation was performed.
The physician shall include in his or her report verification, under
penalty of perjury, of time spent in each of the following activities:
review of records, face-to-face time with the injured worker, and
preparation of the report. Time spent shall be tabulated in increments of
15 minutes or portions thereof, rounded to the nearest quarter hour. The
physician shall be reimbursed at the rate of RV 5, or his or her usual and
customary fee, whichever is less, for each quarter hour

ML101Med. Legal Definition: “Follow-up Medical-Legal Evaluation.
Limited to a follow-up medical-legal evaluation by a physician which
occurs within  nine months of  the date  on which the prior medical-legal
evaluation was performed

Example of ML 101 Disallowed
o        Med-Legal OMFS, ML101 must meet the following criteria:
o        •Follow-up ML evaluation.
o        •Occurs within nine months of initial ML evaluation.
o        •Involves a physical examination.
o        •The physician must verify, under penalty of perjury, the time
spent by him or her on the following activities:
o        •review of records
o        •face-to-face time with the injured worker
o        •preparation of the report (doesn’t include clerical time)
o        •Submitted documentation does not include the full report
generated for the Initial Med-Legal Examination. Without documentation
to support the initial Med-Legal evaluation, a “follow-up” status cannot
be verified. It is noted on page 8 of the submitted report a QME exam
date of 01/03/2014 is listed, however, the actual 01/03/2014 report was
not submitted.  Additionally, the time factor for the 01/03/2014 OME
Exam equates to 1 year, 8 months, 28 days which exceeds the 9 month
time line for a Med-Legal supplemental report.

ML102 Definition: A basic medical evaluation which does not meet the
criteria of any other medical-legal evaluation. Paid at a flat rate of
$625.00 (this normally happens when a ML was requested by party but
none of format and information required for ML101, 103 or 104 are met)

ML 103: Complex Comprehensive Medical-Legal Evaluation. Includes
evaluations which require three of the complexity factors set forth .In a
separate section at the beginning of the report, the physician shall
clearly and concisely specify which of the following complexity factors
were required for the evaluation, and the circumstances which made
these complexity factors applicable to the evaluation.

ML 104: Complex Comprehensive Medical-Legal Evaluation. Includes
evaluations which require four of the complexity factors set forth .In a
separate section at the beginning of the report, the physician shall
clearly and concisely specify which of the following complexity factors
were required for the evaluation, and the circumstances which made
these complexity factors applicable to the evaluation.
o        Repeat: ML104 requires: (1) An evaluation which requires four or
more of the complexity factors listed under ML 103; In a separate
section at the beginning of the report, the physician shall clearly and
concisely specify which four or more of the complexity factors were
required for the evaluation, and the circumstances which made these
complexity factors applicable to the evaluation.
•        ML104 (2) An evaluation involving prior multiple injuries to the
same body part or parts being evaluated, and which requires three or
more of the complexity factors listed under ML 103, including
verification under penalty of perjury of the total time spent by the
physician in each of these activities
reviewing the records
face-to-face time with the injured worker
preparing the report
if applicable, any other activities.

Medical Research as a Complexity Most often missed the importance of
to get 4 complexities: Med. Legal OMFS, “An evaluator who specifies
complexity factor (3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Not  Met –(3) Two or more hours of medical research by the
physician; Med. Legal OMFS, “An evaluator who specifies complexity
factor (3) must also provide a list of citations to the sources reviewed,
and excerpt or include copies of medical evidence relied upon” Criteria
Not Met –in accordance with §9793 (j): "Medical research" is the
investigation of medical issues. It includes investigating and reading
medical and scientific journals and texts. "Medical research" does not
include reading or reading about the Guides for the Evaluation of
Permanent Impairment (any edition), treatment guidelines (including
guidelines of the American College of Occupational and Environmental
Medicine), the Labor Code, regulations or publications of the Division
of Workers' Compensation (including the Physicians' Guide), or other
legal materials.”

Medical-Legal 106 Definition •§9793(l) "Supplemental medical-legal
evaluation" means an evaluation which (A) does not  involve an
examination of the patient, (B) is based on the physician's review of
records, test results or other medically relevant information which was
not available to the physician at the time of the initial examination, (C)
results in the preparation of a narrative medical report prepared and
attested to in accordance with Section 4628 of the Labor Code, any
applicable procedures promulgated under Section 139.2 of the Labor
Code, and the requirements of Section 10606 and (D) is performed by a
qualified medical evaluator, agreed medical evaluator, or primary treating
physician following the evaluator's completion of a comprehensive
medical-legal evaluation.

§ 9795 ML 106: Fees for supplemental medical-legal evaluations. The
physician shall be reimbursed at the rate of RV 5, or his or her usual and
customary fee, whichever is less, for each quarter hour or portion
thereof, rounded to the nearest quarter hour, spent by the physician.
Fees will not be allowed under this section for supplemental reports
following the physician's review of (A) information which was available
in the physician's office for review or was included in the medical record
provided to the physician prior to preparing the initial report or (B) the
results of laboratory or diagnostic tests which were ordered by the
physician as part of the initial evaluation.

ML106: Supplemental medical -legal evaluations: Fees will not be
allowed under this section for supplemental reports following the
physician's review of (A) information which was available in the
physician's office for review or was included in the medical record
provided to the physician prior to preparing the initial report or (B) the
results of laboratory or diagnostic tests which were ordered by the
physician as part of the initial evaluation.
ML100        •ISSUE IN DISPUTE: Provider seeking remuneration for
ML100 Missed Med-Legal

ML100        Claims Administrator denied billed code with indication
“Medical Legal missed appointment code used for communication
purposes only”

ML101        Claims Administrator reimbursed $3403.13 from total billed
amount $6187.50 with rationale “excessive billing, and asserts that
approximately 45% of the 66 page report includes commentary outside
Provider’s area of expertise
ML101
-
94
     Claims Administrator denied reimbursement based on “criteria.”

ML101        The Claims Administrator indicates ML101 units reduced
based on submitted report.

ML101-95
     Claims Administrator denied services indicating: “Payment
denied/reduced for absence of, or exceeded, pre-
certification/authorization.”

ML102        The Claims Administrator based reimbursement on 99214,
Established Patient Evaluation and WC004
Primary Treating Physician Permanent and Stationary Report, as “more
appropriate.”

ML102-95-93
     Claims Administrator denied code indicating “the charge was denied
as the report/documentation does not indicate that the service was
performed”

ML103-86
     Claims Administrator reimbursed ML 103 as 99205 indicating on the
Explanation of Review “The documentation does not support the level
of service billed. Reimbursement was made for a code that is supported
by the documentation submitted with the billing”

ML103-94
     Claims Administrator reimbursed $324.83 after changing ML 103 to
99215 and WC004.
ML104        Claims Administrator denied reimbursement with rationale
“This workers’ compensation claim has been denied”

ML104        Claims Administrator denied ML 104 with rationale “Claim
is denied. No payment will be made.”

ML104        Claims Administrator reimbursed ML 104 as ML 103 with
rationale “services rendered appear to be best described by this code”

ML104
-
95
     Claims administrator down coded ML 104 to ML 103 indicating on
the Explanation of Review “Billing greater than Medical Legal
Allowance” and “Qualified Medical Examiner”

ML104        Claims Administrator denied services with the following
rational: “No Reimbursement was  made for the E/M services as the
documentation does not support a separate significant identifiable E&M
service performed with other services provided. Plan Procedures not
followed.”


ML104 and 96101        The Claims Administrator denied reimbursement
pending documentation
ML104,
73110, 72110, 73562, 73030 and 72040
     Claims Administrator ML104 reimbursement rational: “FCE Not
Requested,” and “Not Authorized.”
ML104-86-92
     The Claims Administrator based reimbursement on “better defining
service,” 99215 Established Patient Evaluation
ML104-86-92
(ML by PTP)         •The Claims Administrator based reimbursement on
“better defining service,” 99215 Established Patient Evaluation
ML104-92 (ML by PTP Requited by Applicant)
     Claims Administrator reimbursed Down-coded the service to
Evaluation and Management  Code 99215, stablished Patient, and
California Reporting Code WC004,  Primary Treating  Physician's
Permanent and. Stationary Report based on the following rational: “The
Official Medical Fee Schedule Does Not List This Code. An Allowance
has been made for a comparable service
ML104-94
     Claims Administrator shows an allowance of $9125.00 on the
Explanation of Review  dated 6/17/2014 for ML 104 indicating
“Recommended payment of this procedure or
supply should be reimbursed only if pre-authorization has been
obtained by the Claims
Examiner
ML104-94
     Claims Administrator down coded ML 104 to ML 103 indicating
"the following are not considered factors or were not met: Record
Review”

ML104-94
     The Claims Administrator denied services requesting re-submission
with “ICD.10” coding.

ML104-94-95        •The Claims Administrator down coded ML 104 to a
ML 102 and reimbursed services $781.25 with the following rational:
“the charge exceeds the Official Medical Fee Schedule  allowance. The
charge has been adjusted to the scheduled allowance.” Claims
Administrator
also disputing the timeliness of second bill review.

ML104-94-95
     The Claims Administrator
reimbursed $4,250.00 with
rationale “reasonable charges on this case would be 17 hours x 4 =68
units


ML104-95
     
ML104-95
     Claims Administrator reimbursed $62.50 of the billed total $2625.00
with indication of  “the charge exceeds the Official Medical Fee Schedule
Allowance. The charge has been adjusted to the scheduled allowance

ML104-95
     Claims Administrator down coded ML 104 to ML 103 with
rationale “Report does not meet 4 or more complexity factors listed
under ML 104 as required by Title 8 CCR 9795”
ML104-95
     Claims Administrator reimbursed 27 units for a total of $1687.50 of
the 99 units billed.

ML104-95
     The Claims Administrator reimbursed the Provider “$1,625.00” of  
“$3,812.50, ”indicating “Official Medical Fee Schedule” rational.
•EOR’s do not indicate ML104level of services down-coded or denied.

ML104-95
     Claims Administrator denied service with rationale “Alternative
services were available and should have been utilized

ML104-95
     Claims Administrator down coded ML 104 to a ML 103and
reimbursed Services $937.50 with the following rational: “the charge
exceeds the Official Medical Fee Schedule allowance. The charge has
been adjusted to the scheduled allowance
.

ML104-95
     Claims Administrator down coded ML 104 to a ML 103
And reimbursed services
$843.75 with the following rational: “documentation doesn’t support
the level of service
.

ML104-95
     The Claims Administrator denied ML104 indicating “Charge exceeds
the Official medical Fee Schedule allowance.”
ML104-95
     Claims Administrator reimbursed $7125.00 indicating “20 hours
billed for records review is a bit excessive”
and only reimbursed Provider for 14.5 hours.

ML104-95-25
     Claims Administrator denied service originally. A third EOR
submitted by Claims Administrator after the dispute had been filed,
shows ML 104 processed with a payment to be made to Provider in the
amount of $4125.00
ML106
-
95
     
ML106-94
     Claims Administrator reimbursed Provider $2,968.75 and then re-
cooped funds for service.
ML106-95
     Claims Administrator reimbursed ML 106 and a separate 99080
which was denied payment.

ML106-96        The Claims Administrator denied reimbursement
pending “authorization.”
All the Information On This Page is
A Table Of Contents of What is
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