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California Workers' Comp
URINE DRUG SCREEN    = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CT SCAN = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
EMG/NCS   = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
8 WEEK 24 LESSON COURSE  IN WORK COMP TREATMENT AND
COLLECTIONS for $325.00 (INDIVIDUAL OR ENTIRE STAFF)
8 WEEK 24 LESSON COURSE  IN WORK COMP
TREATMENT AND COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE STAFF)
6 Month  24 LESSON
COURSE  IN WORK COMP
TREATMENT AND
COLLECTIONS for $325.00
(INDIVIDUAL OR ENTIRE
STAFF)
ANAPROX  = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
ATIVAN = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
CAPSAICIN 0.025%, FLURBIPROFEN 20%, TRAMADOL
10%,MENTHOL 2%, CAMPHOR 2%= Guidelines = Elements
Required in Documentation =Common Errors= Authorized
CARAFATE = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CARISOPRODOL = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
CONSULT WITH PAIN MANAGEMENT = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
HOME HEALTH CARE = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
NEUROLOGICAL CONSULTATION   = Guidelines =
Elements Required in Documentation =Common Errors=
Authorized
PSYCHOLOGICAL EVALUATION = Guidelines = Elements
Required in Documentation =Common Errors= Authorized
DUEXIS= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
EFFEXOR= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FENTANYL= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FEXMID = Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FLECTOR= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FLEXIRIL= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
FLURBIPROFEN CREAM,= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
FLURIFLEX (FLURBIPROFEN/CYCLOBENZAPRINE 15/10
%) CREAM 1= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
GABAPENTIN= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
HYDROCODONE= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
IBUPR= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
KETOPROFEN= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
KLONOPIN= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
LIDOCAINE PAD= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
LIDODERM PATCH= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
LINZESS= Guidelines = Elements Required in Documentation
=Common Errors= Authorized
LORTAB ELIXIR= Guidelines = Elements Required in
Documentation =Common Errors= Authorized
Program: Objections and Responses As Determined by
decisions : ML 104:Claims Administrator reimbursed $2636.72
indicating on the Explanation of Review “In accordance with the
California Official Medical Fee Schedule, Section 9789.15.1, this
service was reduced due to the non-physician practitioner (NPP)
payment methodology. (MNPR)  --incorrect
Program: Objections and Responses As Determined by
decisions :Claims administrator reimbursed $59.12 indicating on the
Explanation of Review “The number of units billed for this
procedure code exceeds the reasonable number usually provided in a
given setting as defined within the Medically Unlikely Edits (MUEs)
which is published and maintained by the Centers for Medicare and
Medicaid Services” This denial is incorrect as these are lab charges
not physician charges.
Program: Objections and Responses As Determined by
decisions : Claims Administrator reimbursed $113.34 of billed
amount $1396.80 indicating on the Explanation of Review “Charge
for pharmaceuticals exceed the fees established by the fee
schedule/UCR rates” Compound Medication Claim Administrator
Incorrect
Program: Objections and Responses As Determined by
decisions : Provider seeking remuneration for the following
Ambulatory Services performed on 11/03/2014: 64635-SG $860.00;
64635 -SG-50 $430.00;64636-SG $568.00; & 64636-SG-50 $568.00.
•Claims Administrator denial rational: “Reimbursement for this
service is not payable to Ambulatory Surgical Centers  --- Incorrect
Program: Objections and Responses As Determined by
decisions :The Claims Administrator did not reimburse the Provider
based on the Multiple Endoscopy guidelines as described in the
OMFS Physician Fee Schedule Regulation effective January 1, 2014.
Therefore, reimbursement of code 29881 is warranted.  
Program: Objections and Responses As Determined by
decisions :G0260-LT  Provider billed the disputed CPT codes on a
UB04, bill type 831 for date of service 10/02/2014. •Claims
Administrator reimbursement rational: “Service not paid under
outpatient facility fee schedule  - incorrect
Program Files Medical Necessity RFA:  Right Elbow Cubital
Tunnel Release: Overturned
Program Files Medical Necessity RFA: Left knee arthroscopy
with partial meniscectomy, possible chondroplasty and possible
removal of loose bodies: Overturned
Program Files Medical Necessity RFA: Lumbar ESI at L5-S1:
Overturned
Program Files Medical Necessity RFA: Computed
Tomography (CT) of the Cervical Spine: Overturned
Program Files Medical Necessity RFA: Physical Therapy (3x
week/6 weeks, 18 Total Visits: Overturned
Program Authorization UR Denials Overturned by IMR:
Psychotropic therapy, once per week for one week: Overturned
Program Authorization UR Denials Overturned by IMR:
TWELVE (12) PHYSIOTHERAPY VISITS :Overturned
Program Authorization UR Denials Overturned by IMR: initial
Ortho Consult for Left Elbow and Left Wrist: Overturned
Program Authorization UR Denials Overturned by IMR: Pain
management consultation: Overturned
Program Authorization UR Denials Overturned by IMR:
Clonidine 0.1mg #90: Overturned
Program Authorization UR Denials Overturned by IMR:
MRI Arthrogram Right Ankle:Overturned
Program Authorization UR Denials Overturned by IMR: Pain
Management Consultation:Overturned
Program Authorization UR Denials Overturned by IMR:
POST-OP PHYSICAL THERAPY FOR THE RIGHT
SHOULDER 3 X 4:Overturned
Program Authorization UR Denials Overturned by IMR:
Follow-up internal medicine evaluation: Overturned
Program Authorization UR Denials Overturned by IMR
Neurosurgical consult: Overturned
Program Authorization UR Denials Overturned by IMR
Retrospective request for Norco 10/325 mg #60
DOS:1/24/14:Overturned
Program Authorization UR Denials Overturned by IMR: Right
Shoulder Arthroscopic Rotator Cuff Repair with Decompression:
Overturned
Program Authorization UR Denials Overturned by IMR:
Med panel to evaluate hepatic and renal function: Overturned
Program Authorization UR Denials Overturned by IMR:
Psychological Evaluation: Overturned
Program Authorization UR Denials Overturned by IMR: Left
Knee Video Arthroscopy, Medial Meniscectomy : Overturned
Program: Objections and Responses As Determined by
decisions : (E/M) service by the same physician on the day of a
procedure:  
New:
Program Authorization UR Denials Overturned by IMR: Post
operative land physical therapy 2 x 8 for the lumbar spine:
Overturned

Psychological testing, 5 units: Overturned

Sunday, July 5, 2015

11:56 AM

Decision rationale: The Chronic Pain Medical Treatment Guidelines, 8 C.C.R. §§9792.20 -9792.26, page(s) pgs. 100-101. has the following to state about Psychological evaluations: Recommended. Psychological evaluations are generally accepted, well-established diagnostic procedures not only with selected use in pain problems, but also with more widespread use in chronic pain populations. Diagnostic evaluations should distinguish between conditions that are preexisting, aggravated by the current injury or work related. Psychosocial evaluations should determine if further psychosocial interventions are indicated. The interpretations of the evaluation should provide clinicians with a better understanding of the patient in their social environment, thus allowing for more effective rehabilitation. (Main-BMJ, 2002) (Colorado, 2002) (Gatchel, 1995) (Gatchel, 1999) (Gatchel, 2004) (Gatchel, 2005) For the evaluation and prediction of patients who have a high likelihood of developing chronic pain, a study of patients who were administered a standard battery psychological assessment test found that there is a Psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems. (Gatchel, 1999) Childhood abuse and other past traumatic events were also found to be predictors of chronic pain patients. (Goldberg, 1999) Another trial found that it appears to be feasible to identify patients with high levels of risk of chronic pain and

to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem. (Linton, 2002) Other studies and reviews support these theories. (Perez, 2001) (Pulliam, 2001) (Severeijns, 2001) (Sommer, 1998) In a large RCT the benefits of improved depression care (antidepressant medications and/or psychotherapy) extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status. (Lin-JAMA, 2003) See "Psychological Tests Commonly Used in the Assessment of Chronic Pain Patients" from the Colorado Division of Workers' Compensation, which describes and evaluates the following 26 tests: (1) BHI 2nd ed -Battery for Health Improvement, (2) MBHI -Millon Behavioral Health Inventory [has been superseded by the MBMD following, which should be administered instead], (3) MBMD -Millon Behavioral Medical Diagnostic, (4) PAB -Pain Assessment Battery, (5) MCMI-111 -Millon Clinical Multiaxial Inventory, (6) MMPI-2 -Minnesota Inventory, (7) PAI -Personality Assessment Inventory, (8) BBHI 2 -Brief Battery for Health Improvement, (9) MPI -Multidimensional Pain Inventory, (10) P-3 -Pain Patient Profile, (11) Pain Presentation Inventory, (12) PRIME-MD -Primary Care Evaluation for Mental Disorders, (13) PHQ -Patient Health Questionnaire, (14) SF 36, (15) SIP -Sickness Impact Profile, (16) BSI -Brief Symptom Inventory, (17) BSI 18 -Brief Symptom Inventory, (18) SCL-90 -Symp

 

Pasted from <http://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR-Decisions2014/IMR2013_1-10000/CM13-0006218.pdf>

 

Created with Microsoft OneNote 2010
One place for all your notes and information

Program Authorization UR Denials Overturned by IMR: Post
operative land physical therapy 2 x 8 for the lumbar spine:
Overturned
PSYCHOLOGY
SURGERY
TESTING
PHYSICAL THERAPY
PHYSICAL THERAPY
MEDICATIONS
OTHERS
ACUPUNCTURE
CHIROPRACTIC
DME
Program Files Medical Necessity RFA: Right Elbow Cubital
Tunnel Release: Overturned
Program Files Medical Necessity RFA: Diagnostic Left L5
Medial Branch Facet Block QYT 1.00: Overturned
Program Authorization UR Denials Overturned by IMR:
PROSPECTIVE REQUEST FOR 1 QUALITATIVE 12 PANEL
URINE DRUG SCREEN :Overturned
Hospital Inpatient Billing and Payments
Medical Legal  Billing  and Payments
Evaluation and Management / Office Visits  
Billing  and Payments
Medical Legal  Billing  and Payments
Surgery Professional Component  Billing  and
Payments
Surgery Outpatient Services Hospital /Facility
Surgery Centers Billing  and Payments
Medication Billing  and Payments
Medical Legal  Billing  and Payments
Medical Testing   Billing  and Payments
Other  Billing and Payments
Program Files Billing and Payment Issues 20526-59-RT
Injection, therapeutic (eg, local anesthetic, corticosteroid),
carpal tunnel Performed on 11/25/2014
Hospital Emergence Room Department   Billing
and Payments
Program Files Billing and Payment Issues code 99283 and
reimbursement of codes 72100 and 71020
Program Files Billing and Payment Issues outpatient services.
Hospital is a Long Term Acute Care Hospital.
Program Files Billing and Payment Issues 63047 primary
procedure for laminectomy
Program Files Billing and Payment Issues 95832, 95831-RT,
95831-LT, 95851-RT, 95851-LT, and 95852 Range of Motion
and Muscle Testing services performed on 03/04/2014
DME   Billing  and Payments
2015 Book Lien Filing, Exceptions and
Time Limits
$225.00
2015 Book PPO Contracts How
They Apply SB 863
2015 PPO Contracts / Silent PPO All
States  Applications and Laws
2015 New Publication
Medical Legal Process – Disputes –QME –
AME- PTP – Interpreters – Copy Services
2015 New Publication
Pain Management / Psychiatric Treatment
2015 Book What Every Adjuster
Should Know About Liens
$225.00
2015 Book What Every Defense Attorney Should
Know  About Lien Disputes
$265.00
2015 Book MPN Issues, Denied Cases, Disputed
Liability,
Contested Liability and Burden of Proof
$235.00
2015 Book Burn Centers
Collections Dispute Book
$275.00
2015 Hospitals Collections
Disputes
2015 Book Appearing at the
WCAB
$235.00
2015 Book Pleadings at WCAB
$375.00
2015 Book Implants,  DME,
Toxicology WCAB Disputes
2015 Book CIGA and Assigned
Claims  Purchased Work Comp
2015 Book Lien Filing,
Exceptions and Time Limits
2015 PPO Contracts / Silent
PPO All States  Applications
and Laws
2015 Book What Every Defense
Attorney Should Know  About Lien
Disputes
2015 Book PPO Contracts
How They Apply SB 863
2015 Book What Every
Adjuster Should Know
About Liens
2015 Book MPN Issues, Denied
Cases, Disputed Liability,
Contested Liability and Burden of
Proof
2015 New Publication
Medical Legal Process – Disputes –
QME –AME- PTP – Interpreters –
Copy Services
2015 New Publication
Pain Management /
Psychiatric Treatment
2015 Book Burn Centers
Collections Dispute Book
2015 Hospitals Collections
Disputes
2015 Book Burn Centers
Collections Dispute Book
2015 Hospitals Collections
Disputes
2015 Book Appearing at
the WCAB
2015 Book Pleadings at
WCAB
2015 Book Implants,  
DME, Toxicology WCAB
Disputes
A Simple Program to ensure Reasonable
Reimbursement (Fee Schedule or Usual  and
Customary)1000 IBR Decisions Posted by billing code
and services -- Each Link opens full IBR decisions
regarding that billing code and billing services listed --
receive immediately via download / email
Over 1000 IBR Decisions Index
Connecting Laws Danger of
Templates
Reference Sheet Collection Process
Common Mistakes By Providers
Liens By Operation of Law /
Medical Legal
Liens By Operation of Law /
Medical Legal /2nd
Liens and how they relate to IBR and
IMR
Liens and how they relate to IBR and
IMR / 2nd
Liens and how they relate to IBR and
IMR / 3rd
Treatment and Payments
Unnecessary Disputes
Reasonable Payments Using the IBR
Process
Getting Treatment Authrized
Treatment and Payments
Unnecessary Disputes 2nd
Fee Schedule / Reasonable Reimbursements and Usual And
Customary Based on IBR Decisions and Case Law
Treatment and Payments
Unnecessary Disputes 3rd
Getting Reasonable Payments
Authorization
Collections
2nd Review and IBR Process /
Sanctions
Introduction Overview
Quick Fixes for Immediately  
Payments
MPNs and Contested Liability Issues
IBR and Charts Part 2
EORs and Medical Legal
2015 Recorded Lectures / Work Shops
For Treatment and Collection Disputes  
/ How to Organize Under SB 863  and
Lien Issues
Medical Necessity Issues Based on MTUS, ODG, ACOEM and
Published Medical Journals
Publications
Publications
Other  Billing and Payments
Other  Billing and Payments

Urine Drug Screening Billing and Payments in 2015 Who's Right and Why.

Saturday, August 8, 2015

2:30 PM

    Urine Drug Screening Billing and Payments in 2015 Who's Right and Why

    The Issues:

    1. Only a limited number of Payers are paying the 80300 series as billed
    1.   Other payers  will not pay anything on the 80300 series stating it has no value.
    1. For billing on the new 2015 G series, Medicare accepting and Paying more value than what IBRs are stating should be bundled
    1. California IBR decisions,  of which California  Providers have to resolve there payment dispute, are still using 2012 Medicare fee schedule for G0431 and bundling all coding.
    1. California IBR recently issued  decision and bundled  all 2015 G series codes under G0431 at $119.00

    Solutions:

    1.  80300 has a value under worker comp laws, therefore rejections of no payments are incorrect
    1. IBRs are in error in  bundling  all code under G0431 and medicare already stated this in  2014, not all are bundled
    1. Have to overcome incorrect IBR decisions  using present law to overcome improper objections and IBR decisions
    1. Providers have to understand the Coding to overcome incorrect  objections and  know how to Appeal incorrect IBR decisions, as they are using wrong laws to bundled all under G0431
    1. Medicare is aware, the changes, that the 2011 changes in coding to G0431 etc.,  did not result in reasonable reimbursement.
    1. G0431 in most  circumstances are  incorrect as being applied by IBR decisions.
    1. Not getting or understanding the laws and methods to contest underpayments  or no payments, if it the only issue is amount of payments closes the door to contest the amount of underpayments -- i.e. no redress -- So sitting on wrongfully reduced bills does not bring about reasonable reimbursement.

     California Work Comp:

    Can bill the 80300 series if documentation justifies, however one has to apply the work comp rules to apply a monetary value  for payment of those codes.

    Can Bill the G series, but once again,  most payers will copy what IBR decisions reflect and most providers are not understanding the codes as of yet to warrant a positive decision other than bundling under G0431 at $119.00 or thereabouts.

    ANALYSIS AND FINDING

    Based on review of the case file the following is noted:

    ·ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes 81002, 82570, G6040, G6039, 80500, G6036, 80184, G6037, G6053, G6034, G6032, G6030, G6052, G6031, G6045, G6046, G6043, G6056 & 83789

    ·Provider states the services were for quantitative drug testing, not qualitative high complexity. Services were for a drug screening of high complexity.

    ·Claims Administrator denied codes indicating on the Explanation of Review “We are unable to recommend an additional allowance as your billing was reviewed in accordance with the Official Medical Fee Schedule of California, which was adopted by the Administrative Director of the Division of Industrial Accidents for Workers’Compensation Claims”

    ·Moderate v. High complexity as defined by Centers for Disease Control Clinical Laboratory Improvement Amendments (CLIA), “Clinical laboratory test systems are assigned a moderate or high complexity category on the basis of seven criteria given in the CLIA regulations. For commercially available FDA-cleared or approved tests, the test complexity is determined by the FDA during the pre-market approval process. For tests developed by the laboratory or that have been modified from the approved manufacturer’s instructions, the complexity category defaults to high complexity per the CLIA regulations, See 42 CFR 493.17

    High complexity of the toxicology test performed; results reporteda computerized measure of each drug screened which the Provider did submit. ·Quantitative Levels: A drug can be detected ina donor's sample andstill be reportedasnegative. A laboratory has what iscalled, "cutoff levels". These levels are designed toscreenout some over?the?counter pharmaceuticals or vitamins. ·Due to the complexity of the toxicology test performed,the laboratory services shall be paid in accordance with HCPCS code G0431.

    ·Upon review of Centers for Medicare & Medicaid Services (CMS) guidelines, HCPCS code G0431 is reported with only one unit of service regardless of the number of drugs screened. The testing described by G0431 includes all CLIA high complexity urine drug screen testing as well as any less complex urine drug screen testing performed at the same patient encounter.

    ·Disputed Codes 82055 is not inclusive to G0431 and it is recommended that the code be reimbursed separately in accordance with Title 8, California Code of Regulations, §9789.50 Laboratory Fee Schedule.

    ·Based on information reviewed, reimbursement of G0431 is warranted.

    Analysis and Findings:

    Based on review of the case file the following is noted:

    ·ISSUE IN DISPUTE: Provider dissatisfied with reimbursement of billed codes 82055, 82205, 82145,80154, 80299-59, 82520, 80299-59, 83840, 83925-59, 83986, 83992, 81002, 80152.

    ·Provider was reimbursed $21.59 and is seeking additional reimbursement of $266.34.

    ·Claims Administrator bundled the billed codes82205, 82145, 80154, 80299 59,82520,80299 59,83840, 83925 59, 83992 and 80152into HCPCS G0434 indicating thefollowing on the Explanation of Review(EOR): “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.”

    ·The Provider submitted a copy of the laboratory test results and Provider’s Clinical Laboratory license. The toxicology results submitted report a quantitative measure of each drug screened (Amphetamine, Barbiturates, Benzodiazepine,Cannabinoids,Cocaine Metabolites, Ecstasy, Methadone Metabolite, Opiates, Oxycodone,PCP, Tricyclics), . HCPCS code G0434 is utilized to report urine drug screening performed by a test that is CLIA waived or moderate complexity test. Due to the complexity of the toxicology test performed, the levels tracked and results obtained the billed procedure codes 82205, 82145, 80154, 80299 59,82520,80299 59,83840, 83925 59, 83992 and 80152shall be paid in accordance with HCPCS code G0431. The HCPCS code G0431 is reported with only one unit of service regardless of the number of drugs screened. The testing described by G0431 includes all CLIA high complexity urine drug screen testing as well as any less complex urine drug screen testing performed at the same patient encounter.·The description of HCPCS code G0431 is "Drug screen, qualitative; multiple drug classes by high complexity test method (e.g. immunoassay, enzyme assay), per patient encounter."

    ·The drug screen services provided were of high complexity test method. The HCPCS code G0431 criteria has been met based on the documentation submitted by the Provider. Therefore, the code assignment G0434 and payment made by the Claims Administrator was not correct.

    ·The billed procedure code CPT 83986, 81002 and 82055 are not considered part of the drug panel and should be paid separately. The description of CPT 83986 is "pH; body fluid, not otherwise specified." The description of CPT 81002 is " Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy ." The description of CPT 82055 is " Alcohol any specimen except breath.”·PPO Contract was received and a 10% discount is to be applied.

    ·DETERMINATION OF ISSUE IN DISPUTE: Based on the documentation submitted, additional reimbursement of $111.51to be madebased on the Official MedicalFee Schedulefor HCPCS code G0431, 83986, 81002 and 82055

    ANALYSIS AND FINDING

    Based on review of the case file the following is noted:

    ·ISSUE IN DISPUTE: Provider seeking additional remuneration for 82486 Gas/liquid chromatography Drug Testing Performed on 02/18/2015.

    ·Claims Administrator reimbursement rational based on “unauthorized” service.

    ·Authorization for “Urine Toxicology Screen”indicates “Approved by Physician Advisor,”on 01/23/2015.

    ·Pursuant to Labor Code section 5307.1(g)(2), the Administrative Director of the Division of Workers’ Compensation orders that the pathology and clinical laboratory fee schedule portion of the Official Medical Fee Schedule (OMFS) contained in title 8, California Code of Regulations, section 9789.50, has been adjusted to conform to the changes to the Medicare payment system that were adopted by the Centers for Medicare & Medicaid Services (CMS) for calendar year 2014. Effective for services rendered on or after January 1, 2013, the maximum reasonable fees for pathology and laboratory services shall not exceed 120% of the applicable California fees set forth in the calendar year 2012 Clinical Laboratory Fee Schedule. Based on the adoption of the CMS payment system, CMS coding guidelines and fee schedule were referenced during the review of this Independent Bill Review (IBR) case

    .·CMS 1500 reflect 82486x17

    ·Moderate v. High complexity as defined by Centers for Disease Control Clinical Laboratory Improvement Amendments (CLIA), “Clinical laboratory test systems are assigned a moderate or high complexity category on the basis of seven criteria given in the CLIA regulations. For commercially available FDA-cleared or approved tests, the test complexity is determined by the FDA duringthe pre-market approval process. For tests developed by the laboratory or that have been modifiedfrom the approved manufacturer’s instructions, the complexity category defaults to high complexity per the CLIA regulations, See 42 CFR 493.17.·A similar code historically assigned for CPT 82486 is G0431“multiple drug classes by high complexity test method.”

    ·As defined by the US Centers for Medicare and Medicaid Services (CMS), HCPCS G0431 is defined as follows: G0431 (Drug screen, qualitative;multiple drug classes by high complexity test method(e.g., immunoassay, enzyme assay), per patient encounter) will be used to report more complex testing methods, such as multi-channel chemistry analyzers, where a more complex instrumented device is required to perform some or all of the screening tests for the patient. This code may only be reported if the drug screen test(s) is classified as CLIA high complexity test(s) with the following restrictions:omay only be reported when tests are performed usinginstrumented systems (i.e., durable systems capable of withstanding repeated use).oCLIA waived tests and comparable non-waived tests may not be reported under test code G0431; they must be reported under test code G0434.oCLIA moderate complexity tests should be reported under test code G0434 with one (1) Unit of Service (UOS).oG0431 may only be reported once per patient encounter.

    ·Lab Report for date of service reflects high complexity computerized analysis.

    ·Reimbursement is warranted for 82486as G0431 x 1 unit.

    ·Contractual Agreement not available for IBR, 100% OMFS will be utilized.

    Conclusions: In 2014 and 2015 one does not have to play the billing code game to get reasonable reimbursement, one just has to understand the 2015  and 2014 Medicare and how work comp puts a reasonable value.  In addition and this has been the issue since 2013, not all coding is bundled under G0431 and this is a major issue with  Providers in billing, lack of correct documentation and assertion of  appropriate laws, simple error causing major losses.

    The HCPCS codes listed below are new for 2015 and are subject to CLIA edits. The list does not include new HCPCS codes for waived tests or provider-performed procedures. The HCPCS codes listed below require a facility to have either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid, current, CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2) or with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) must not be permitted to be paid for these tests.

    • G0464 - Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3)

    • G6030 – Amitriptyline;

    1. • G6031- Benzodiazepines;
      • G6032 – Desipramine;
      • G6034 – Doxepin;
      • G6035 – Gold;
      • G6036 – Assay of imipramine;
      • G6037 – Nortriptyline;
      • G6038 – Salicylate;
      • G6039 – Acetaminophen;
      • G6040 – Alcohol (ethanol); any specimen except breath;
      • G6041 – Alkaloids, urine, quantitative;
      • G6042 – Amphetamine or methamphetamine;
      • G6043 – Barbiturates, not elsewhere specified;
      • G6044 – Cocaine or metabolite;
      • G6045 – Dihydrocodeinone;
      • G6046 – Dihydromorphinone;
      • G6047 – Dihydrotestosterone;
      • G6048 – Dimethadione;
      • G6049 – Epiandrosterone;
      • G6050 – Ethchlorvynol;
      • G6051 – Flurazepam;
      • G6052 – Meprobamate;
      • G6053 – Methadone;
      • G6054 – Methsuximide;
      • G6055 – Nicotine;
      • G6056 – Opiate(s), drug and metabolites, each procedure;
      • G6057 - Phenothiazine;
      • G6058 - Drug confirmation, each procedure;
      • 80163 - Digoxin level;
      • 80165 - Valproic acid level;
      • 80300 - Drug screen;
      • 80301 - Drug screen;
      • 80302 - Drug screen;
      • 80303 - Drug screen;
      • 80304 - Drug screen;
      • 80320 - Alcohols levels;
      • 80321 - Alcohols levels;
      • 80322 - Alcohols levels;
      • 80323 - Alkaloids levels;
      • 80324 - Amphetamines levels;
      • 80325 - Amphetamines levels;
      • 80326 - Amphetamines levels;
      • 80327 - Anabolic steroids levels
      • 80328 - Anabolic steroids levels
      • 80329 - Analgesics levels;
      • 80330 - Analgesics levels;
      • 80331 - Analgesics levels;
      • 80332 - Antidepressants levels;
      • 80333 – Antidepressants levels;
      • 80334 – Antidepressants levels;
      • 80335 – Antidepressants levels
      • 80336 – Antidepressants levels;
      • 80337 - Antidepressants levels;
      • 80338 – Antidepressants levels;
      • 80339 - Antiepileptics levels;
      • 80340 – Antiepileptics levels;
      • 80341 – Antiepileptics levels;
      • 80342 – Antipsychotics levels;
      • 80343 – Antipsychotics levels;
      • 80344 – Antipsychotics levels;
      • 80345 – Barbiturates levels;
      • 80346 - Benzodiazepines levels;
      • 80347 – Benzodiazepines levels;
      • 80348 – Buprenorphine level
      • 80349 – Cannabinoids levels
      • 80350 - Cannabinoids levels
      • 80351 - Cannabinoids levels;
      • 80352 - Cannabinoids levels;
      • 80353 – Cocaine level;
      • 80354 – Fentanyl level;
      • 80355 – Gabapentin level non-blood;
      • 80356 – Heroin metabolite level;
      • 80357 – Ketamine and norketamine levels;
      • 80358 – Methadone level;
      • 80359 – Methylenedioxyamphetamines levels;
      • 80360 – Methylphenidate level;
      • 80361 – Opiates levels;
      • 80362 – Opioids levels;
      • 80363 – Opioids levels;
      • 80364 – Opioids levels;
      • 80365 – Oxycodone levels;
      • 80366 – Pregabalin level;
      • 80367 – Propoxyphene level;
      • 80368 – Sedative hypnotics (non-benzodiazepines) levels
      • 80369 – Skeletal muscle relaxants levels;
      • 80370 – Skeletal muscle relaxants levels;
      • 80371 – Synthetic stimulants levels;
      • 80372 – Tapentadol level;
      • 80373 – Tramadol level;
      • 80374 – Stereoisomer (enantiomer) drug analysis;
      • 80375 – Drugs or substances measurement;
      • 80376 – Drugs or substances measurement;
      • 80377 - Drugs or substances measurement;
      • 81246 - Test for detecting genes associated with blood cancer;
      • 81288 - Test for detecting genes associated with colon cancer;
      • 81313 - Test for detecting genes associated with prostate cancer;
      • 81410 - Test for detecting genes associated with heart disease;
      • 81411 - Test for detecting genes associated with heart disease;
      • 81415 - Test for detecting genes associated with diseases;
      • 81416 - Test for detecting genes associated with disease;
      • 81417 - Reevaluation test for detecting genes associated with disease;
      • 81420 - Test for detecting genes associated with fetal disease;
      • 81425 - Test for detecting genes associated with disease;
      • 81426 - Test for detecting genes associated with disease;
      • 81427 - Reevaluation test for detecting genes associated with disease;
      • 81430 - Test for detecting genes causing hearing loss;
      • 81431 - Test for detecting genes causing hearing loss;
      • 81435 - Test for detecting genes associated with colon cancer;
      • 81436 - Test for detecting genes associated with colon cancer;
      • 81440 - Test for detecting genes associated with cancer of body organ;
      • 81445 - Test for detecting genes associated with cancer of body organ;
      • 81450 - Test for detecting genes associated with blood related cancer;
      • 81455 - Test for detecting genes associated with cancer;
      • 81460 - Test for detecting genes associated with disease;
      • 81465 - Test for detecting genes associated with disease;
      • 81470 - Test for detecting genes associated with intellectual disability;
      • 81471 - Test for detecting genes associated with intellectual disability;
      • 81519 - Test for detecting genes associated with breast cancer;
      • 83006 - Test for detecting genes associated with growth stimulation;
      • 87505 - Detection test for digestive tract pathogen;
      • 87506 - Detection test for digestive tract pathogen;
      • 87507 - Detection test for digestive tract pathogen;
      • 87623 - Detection test for human papillomavirus (hpv);
      • 87624 - Detection test for human papillomavirus (hpv);
      • 87625 - Detection test for human papillomavirus (hpv);
      • 87806 - Detection test for HIV-1;
      • 88341 - Special stained specimen slides to examine tissue;
      • 88344 - Special stained specimen slides to examine tissue;
      • 88364 - Cell examination;
      • 88366 - Cell examination;
      • 88369 - Microscopic genetic examination manual;
      • 88373 - Microscopic genetic examination using computer-assisted technology;
      • 88374 - Microscopic genetic examination using computer-assisted technology; and
      • 88377 - Microscopic genetic examination manual.

     

    see more at: www.workcompliens.com

     

    Toxicology / Urine Drug Screening

     

     

    see more at: www.workcompliens.com

     

    Toxicology / Urine Drug Screening

     

     

 

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WC: When Liens are Not Required, Nor Subject to the Time to File Liens

Monday, August 10, 2015

7:42 AM

 

Three years into SB 863 and we are seeing more and more Providers using other laws and methods under SB 863,  to get orders for payments without the necessity of filing liens and or subject to the time to file liens. Of which most are producing better and or more expediency of results.

1.  Providers' services are denied based on the issue of treatment outside the MPN. The applicant attorney  does a expedited hearing and the Court rules insufficient offer of treatment, treatment outside the MPN allowed at employers expense. All providers in that case can now either request and get a order for payment without a lien filed or time limits, depending what the EOR  stated.

2. Copy services files a "Petition for Non-IBR Medical Legal Disputes",  as services medical legal, just by the filing of the Petition allows the Provider to recovery without a lien and or lien time limit.  This applies to all providers doing a medical-legal.

3. The case is a denied based on the defense of "Post Termination",  Lien Claimant does a lien trial, judge holds that employer had notice of the injury prior to termination, other providers who have not filed a lien or past the time to file can now get an order for payments, depending on the what the EOR states either through the IMR or IBR process (or second review).

4. Petition for Costs

5. The case denied, case in chief admitted injury Providers can get orders for payments without lien and or lien fees.

6. Case denies the psych injury, Psych Provider does  a Medical -Legal, even though not a QME or AME, The provider if no payments made,  can do a "Petition for Non-IBR Medical Legal Dispute." This also applies to testing, evaluations, as well as AME and QME.

7.If the Defense in an admitted claim and denied body part  defers UR, when the issue is resolved but treatment already provided, a mandatory UR has to take place, no lien or  time to file liens required.

There are 10 more examples where SB 863 set a system up  where liens and or time limits of liens are not mandated, even Petitioning the Director for enforcement. However just like all laws under SB 863, it requires  detail and understanding of how the above Procedures  work and their applications.

There are a good number of laws that most Providers are starting to utilize under SB 863. 

The Provider was asked to perform a psychiatric consultation and submit a report on the injured worker for the purpose of clearance for surgery.

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August 14 New Fee Schedule Issues Posted

WC: Urine Drug Testing in Pain Management/ Authorization and Payments

Friday, August 14, 2015

7:24 PM

 

 

Urine drug testing (UDT) has become “an essential feature of pain management, as physicians seek to verify adherence to prescribed opioid regimens and to detect the use of illicit or unauthorized licit drugs.”

 

Although, the medical necessity of UDT is essential in monitoring pain management with pain   medication, the payments or these tests, outside billing for Medicare has gone from one extreme to another, accountable by no less of  the publicized asserted abuse and actual abuse on the money side of these services.

 

I read one article that stated a Doctor was testing all senior citizens for cocaine, as an example for abuse, however for industrial injuries testing for cocaine is a must, therefore some of the publicized abuses do not fit the same for injured workers.

 

Medical Necessity:

 

We have four sources that reference medical necessity for Urine Drug screening:

 

  1.   CA MTUS Chronic Pain 2009 Guidelines. MTUS Chronic Pain Guidelines support the use of urine drug screening to monitor for issues of abuse when treating with chronic narcotic pain medications. No set frequency is specifically recommended per the guidelines.

 

  1. MTUS Chronic Pain Guidelines section on opiates--steps to avoid misuse/addiction--frequent random urine toxicology screens are recommended in particular for those at high risk of abuse. MTUS pages94-95 for "Steps to avoid opioid misuse", recommend frequent random urine toxicology screens

 

  1. ODG guidelines on Urine Toxicology screening state the following: Indications for UDT: At the onset of treatment: (1) UDT is recommended at the onset of treatment of a new patient who is already receiving a controlled substance or when chronic opioid management is considered. Urine drug testing is not generally recommended in acute treatment settings (i.e. when opioids are required for nociceptive pain). (2) In cases in which the patient asks for a specific drug. This is particularly the case if this drug has high abuse potential, the patient refuses other drug treatment and/or changes in scheduled drugs, or refuses generic drug substitution. (3) If the patient has a positive or "at risk" addiction screen on evaluation. This may also include evidence of a history of comorbid psychiatric disorder such as depression, anxiety, bipolar disorder, and/or personality disorder (4) Ifaberrant behavior or misuse is suspected and/or detected. Ongoing monitoring: (1) If a patient has evidence of a "high risk" of addiction (including evidence of a comorbid psychiatric disorder (such as depression, anxiety, attention-deficit disorder, obsessive-compulsive disorder, bipolar disorder, and/or schizophrenia), has a history of aberrant behavior, personal or family history of substance dependence (addiction), or a personal history of sexual or physical trauma, ongoing urine drug testing is indicated as an adjunct to monitoring along with clinical exams and pill counts (2) If dose increases are not decreasing pain and increasing function, consideration of UDT should be made to aid in evaluating medication compliance and adherence.

 

  1. Published Medical Papers such as Urine Drug Testing as an Evaluation of Risk By Ted Jones, PhD, James D. McCoy, FNP-BC, Todd Moore, PhD and Susan Daffron, FNP ---While some studies seek solely to identify the presence of illicit or unauthorized prescription substances, the absence of a prescribed opioid medication—hereafter described as an “unexpected negative” finding—also raises a variety of clinically relevant possibilities:

 

  1. • patient never took the medication
    • patient took the medication but was for some reason unable to absorb the medication
    • patient took the medication but for some reason was unable to excrete the medication or its metabolites
    • patient last took the medication too many hours before the test for a detectable level to be present
    • patient lost the medication
    • patient sold or otherwise illicitly distributed the medication
    • medication was stolen
    • any combination of possibilities

 

The standard urine toxicology/drug screen is qualitative, will be able to tell what  drugs are  in your system ==quantitative tells the quantity

 

  •  Initial Screening An initial Enzyme Immunoassay (EIA) test screens for the presence of opiates, benzodiazepines, illicits and other prescribed or non-prescribed medications.

 

  • Confirmation Testing If the EIA test result is positive, the sample undergoes confirmation testing through one of the following methods:

 

  • Gas chromatography-mass spectrometry (GC/MS) is used to create a fingerprint-like match for each detected prescription medication or illicit. This technology’s superior sensitivity can detect drugs or metabolites at some of the lowest levels in the industry.

 

  • Liquid chromatography – tandem mass spectrometry (LC/MS/MS) is used when optimal specificity and sensitivity are required to determine the absence or presence of your patients’ prescribed medications as well as the presence of non-prescribed medications or illicit.

 

As to medical necessity in pain management testing in most case should be authorized as it is essential in any and all use of  medications.

 

Payments:

 

To survive the payment disputes regarding UDT for industrial injuries, one has to have enough law to justify a reasonable reimbursement for all carries as payments vary, with the majority on the low side.

Not only is knowing the laws to  justifying a uniformity of payments based on Medicare ground rules, but one has to understand the processes in industrial injury cases to bring to light those disputes to resolve payments in a set uniformity of reasonable payments.

 

In short, some Providers are getting a mix of payments, with the norm being 10 percent or less paying reasonable and 80 to 90% paying unreasonable, resulting in not finding what is reasonable reimbursement, end result substantial losses.

In 2015, if the law states one should be paid a certain amount, the acceptance of less, because of lack of understanding the laws and or how to get reasonable payment when paid incorrectly, makes little sense, but that is essentially where most are, in the billing and payments of UDT.

 

In short most are stilling playing the coding game, hitting pay dirt with some payers, while the majority of their accounts and services substantially underpaid. As just what has been happening in the last three years those codes will be rebooted and back to 100% paying unreasonable,  luck of billing codes do not pay off in the long run. One has to understand and justify the payment system. The question is not what billing codes are paying reasonable, but why are they and why are some paying the same code unreasonable , and why are IBRs stilling bundling all codes under G0431, master those 3 questions and one can achieve uniformity of reasonable payments and actually make a justifiable legal argument if the issue has to be resolved by a dispute forum  that rules on those matters..

 

Medicare changed the coding and  the reimbursement, because the interpretation of bundling everything under G0431 dd not bring about reasonable reimbursement and or was being interpreted incorrectly, not because those codes were working, if they were, changes would not have been made. However, the key, because the several changes, is on the Provider to justify reasonable reimbursement for all billing,  for all payers that  equate payments based on Medicare reimbursement rules.

 

In industrial injuries, one is right in billing any adopted billing codes as long as the services are actually performed, i.e. the 80300 codes although Medicare has not put a value  to those and requires the 2015 G series . For example those billing the 80300 series do not understand the laws as to why a small percent are paying well on 80300 series and how to bring all their services up to the same reimbursement level for all payers. They actually think it is an error by payers, which is an incorrect conclusion  on their part. resulting in a lost of 80% of their services.

 

Payments .for urine drug screening has a many opinions as there are billing codes. I have even read one post where they stated the new codes were for identification purposes and not payments, that is clearly what Medicare is not stating.

Medicare allows the G series codes unbundled, unless specifically stated  as bundled under G0431 or G0434 which are few compared to those that are not bundled. Therefore billing both  the G0431 and the G series when tests are warranted.

Some States have adopted their  own fee schedule regarding payments for urine drug screen, while a few make there reimbursement based on Medicare payments. Example, Texas who uses Medicare is very liberal in payments never bundling any codes but each one separately payable including recognizing 82486.

 

California has one of the lowest reimbursement over the last three years, basically because insurance companies follow the reimbursement rates decided by IBR decisions , in which they have consistently bundled  every billing code under G0431 - However in 2014/2015 Medicare clarified what was bundled under G0431 and which was not:

 

The below is an example of an IBR decisions in which it was incorrect in bundling all codes under G 0431:

A posted IBR (independent Bill review) decision errors in bundling  all the following codes under G0431= $119.95:

 

81002, 82570, G6040, G6039, 80500, G6036, 80184, G6037, G6053, G6034, G6032, G6030, G6052, G6031, G6045, G6046, G6043, G6056 & 83789,  The is not what Medicare states these codes should be paid.

Not taking into consideration the medical necessity of the tests or the documentation submitted by the Provider in this case, the review should have been as follows under Medicare payments system;

The Provider should have billed G0431 for the following bundled codes:

 

• Bundled =qualitative =G6052, Meprobamate = Meprobamate, qualitative analysis Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

• Bundled G6045, Dihydrocodeinone = Dihydrocodeinone, qualitative Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

• Bundled G6046, Dihydromorphinone Dihydromorphinone, qualitative Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

• Bundled G6043 Barbiturates, not elsewhere specified Barbiturates,

Qualitative Follow 2014 CMS guidance including the use of G0431, G0434 and 80102 as appropriate

 

The below billing codes / tests are not bundled under G0431 but have a separate money  value. The Provider in addition to billing G0431 for the bundled codes, should have billed the below unbundled codes each with a separate payable value, if justified by medical necessity of the test or authorization, based on the billing codes the provider submitted in this case.

 

• Not Bundled =81002, = G6058 = Drug confirmation, each procedure = $

• Not Bundled= G6040,= Alcohol (ethanol); any specimen except breath= $

• Not Bundled G6039= Acetaminophen = $

• Not Bundled G6036, Imipramine = $

• Not Bundled G6037, Nortriptyline = $

• Not Bundled G6053, Methadone = $

• Not Bundled G6034, Doxepin = $

• Not Bundled G6032, Desipramine = $

• Not Bundled G6030, Amitriptyline = $

• Not Bundled G6031, Benzodiazepines = $

• Not Bundled G6056 Opiate(s), drug and metabolites, each procedure = $

 

If the Provider billed correctly and submitted the required documents, the decision to bundled all bill codes under G0431 is incorrect for dates of services in 2015 and 2014.

 

In this case the Provider should have appealed the IBR decision with the correct law.

by: www.workcompliens.com

 

 

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Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
URINE DRUG SCREEN    = Guidelines =
Elements Required in Documentation =Common
Errors= Authorized
CT SCAN = Guidelines = Elements Required in
Documentation =Common Errors= Authorized
EMG/NCS   = Guidelines = Elements Required
in Documentation =Common Errors= Authorized
CONSULT WITH PAIN MANAGEMENT =
Guidelines = Elements Required in
Documentation =Common Errors= Authorized
PSYCHOLOGICAL EVALUATION =
Guidelines = Elements Required in
Documentation =Common Errors= Authorized
Program Files Medical Necessity RFA:  Right
Elbow Cubital Tunnel Release: Overturned
Program Files Medical Necessity RFA: Left
knee arthroscopy with partial meniscectomy,
possible chondroplasty and possible removal of
loose bodies: Overturned
Program Files Medical Necessity RFA: Lumbar
ESI at L5-S1: Overturned
Program Files Medical Necessity RFA:
Computed Tomography (CT) of the Cervical Spine:
Overturned
Program Files Medical Necessity RFA: Physical
Therapy (3x week/6 weeks, 18 Total Visits:
Overturned
Program Authorization UR Denials
Overturned by IMR: Psychotropic therapy, once
per week for one week: Overturned
Program Authorization UR Denials Overturned
by IMR: TWELVE (12) PHYSIOTHERAPY
VISITS :Overturned
Program Authorization UR Denials Overturned by
IMR: initial Ortho Consult for Left Elbow and Left
Wrist: Overturned
Program Authorization UR Denials
Overturned by IMR: Pain management
consultation: Overturned
Program Authorization UR Denials Overturned
by IMR: MRI Arthrogram Right Ankle:Overturned
Program Authorization UR Denials Overturned by
IMR: Pain Management Consultation:Overturned
Program Authorization UR Denials Overturned
by IMR: POST-OP PHYSICAL THERAPY FOR
THE RIGHT SHOULDER 3 X 4:Overturned
Program Authorization UR Denials Overturned
by IMR: Follow-up internal medicine evaluation:
Overturned
Program Authorization UR Denials Overturned by
IMR Neurosurgical consult: Overturned
Program Authorization UR Denials Overturned
by IMR: Right Shoulder Arthroscopic Rotator Cuff
Repair with Decompression:
Overturned
Program Authorization UR Denials Overturned
by IMR: Med panel to evaluate hepatic and renal
function: Overturned
Program Authorization UR Denials
Overturned by IMR: Left Knee Video
Arthroscopy, Medial Meniscectomy : Overturned
Program Authorization UR Denials Overturned
by IMR: Post operative land physical therapy 2 x 8
for the lumbar spine: Overturned
Program Authorization UR Denials Overturned
by IMR: Post operative land physical therapy 2 x 8
for the lumbar spine: Overturned
Program Files Medical Necessity RFA: Right
Elbow Cubital Tunnel Release: Overturned
Program Authorization UR Denials Overturned by
IMR: PROSPECTIVE REQUEST FOR 1
QUALITATIVE 12 PANEL URINE DRUG SCREEN
:Overturned
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Authorization/Medical Necessity:
MTUS
ODG
ACOEM
Published Medical Journals
Translated =Authorization/Medical Necessity:  =MTUS=ODG=ACOEM=Published Medical Journals=For Documentation
for Authorization in  The of Treatment Injured Workers  / Improved and Updated Weekly

WC: Simplifying: Authorization, Payment Disputes, Contested Liability /Denied Claims and Pleadings.

Sunday, August 30, 2015

8:29 PM

2015, nothing is simple, every day they publish a IBR decision, an IMR decision, or a WCAB decision, it causes a ripple effect in all laws already in place, therefore, few things remain the same, sometimes slight changes sometime major, but never the  less changes.

 

The idea is to keep ahead of those ripples in laws and application before the equate to losses or sometimes to be used as a benefit interpretation of existing laws, which is common in IBR and IMR decisions.

 

We have reached a stage where a Provider who just has the MTUS guidelines  is not enough, as the IMR decisions overturning or upholding UR denial addresses, the ODG, ACOEM and published medical papers, and then the essential requirement of what needs to be put in the medicals, a check list more or less.

 

We have fee schedule disputes that have gone beyond billing codes, documentation, modifiers , what must be shown, bundled not bundled in other services and the Medicare application. Massive EORs, incorrect  reductions and 0 payments for authorized services, second review requests and IBRs a must, but the information and documents required can cause some to forgo what should be paid.

 

MPNs, contested liability issues have reached far into their requirement of knowing case laws and subsections that interact with other laws. WCAB not producing what one would expect, preparedness of laws and documents, an essential element.

Pleadings, essential in all Providers' office even prior, to the WCAB which allows enforcement   of rights, but if not used or understood looses.

 

Templates that contain generalities no longer work, vague arguments with adjusters do not produce what it use too.

 

3000 or more IBR decisions to analysis, over 300,000 IMR decisions to understand, thousands of laws, and hundreds of WCAB decisions that must be understood.

With a multiple of Providers and services, the question, can this information be put in one place, made easy to use and translated, not just the decisions but easy to understand how they apply.

 

The answer, is that there is too much information, and the updates happen often to ensure simplicity, so  each Provider has to have a customized program specific to their practice to achieve simplicity, that is exactly what has been created .

Not just IMR, IBR and WCAB decisions, but creating information from their patterns, as I have found just giving some; IBR, IMR or WCAB  decisions is not enough, it has to be simplified for accurate use.

 

I had a conversation with a collection company last week, and he said something that made sense, as I was nonstop going through all the laws, he said it all needed to be translated into a usable format to have value. Which is 100% true, all the laws has to be translated so someone never in the industry before can know how and when it applies and to understand the significance of each law, each IBR decision, each IMR decision and each WCAB decision as applied to and interacted with each other.

 

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