Workers Compensation Fee Schedule as of 3/1/15

Worker's Compensation Fee ScheduleAs of March 1, 2015 fees for certain workers compensation services have increased along with Medicare fee changes.  Below is a chart which shows some common codes and the 2014 fees vs. the 3/1/15 fees for California Workers Compensation.  Record review is still a bundled code and still not payable without a 5307.1 contract.  Reports are generally still not payable unless it is a Permanent and Stationary Report or if the report is requested by a QME or by the Administrative Director of the DWC.

 

 

CPT Code Description 2014 Fee 3/1/15 Fee
PSYCH CODES
90791 Psychological Eval 150.51 155.64
90792 Psychiatric Eval 162.26 174.82
90833 Psychiatric therapy add on code with E&M 74.27 78.05
90834 45 min psychotherapy 96.06 100.28
90837 60 min psychotherapy 143.83 150.49
90901 Biofeedback 47.77 47.78
96101 Psych Testing 90.66/hr 94.87/ hr
96118 Neuropsych Testing by PhD 113.37/hr 118.29/hr
96118 Neuropsych Testing by tech 98.31/hr 103.77/hr
EVALUATION AND MANAGEMENT CODES
99205 Initial OV High complexity 237.67 252.73
99204 Initial OV 191.11 201.77
99203 Initial Ov 125.39 133.40
99215 Ov for established patient 167.15 178.59
99214 Ov for established patient 125.14 132.93
99213 Ov for established patient 84.99 89.81
99354 Extended Face to Face 1st hour 114.35 120.98
99355 Extended Face to Face each additional hour 111.68 117.23
REPORTS
WC002 PR2 11.91 12.01
WC003 PR3 157.68 158.94 max
WC004 PR4 181.48 182.93

 

Documentation of the level of service is key to getting paid appropriately.  Many carriers are down coding 99205 to 99203 and even 99202 in some cases.

For Initial Office Visits the codes require all 3 components:

99201 – Presenting problems(s):  Minor (Time typically 10 minutes)

  • Problem focused history
  • Problem focused examination
  • Medical decision making that is straightforward

99202 –  Presenting problem(s): Low to moderate severity (Time typically 20 minutes)

  • Expanded problem focused history
  • Expanded problem focused examination
  • Medical decision making is straightforward

99203 – Presenting problem(s): Moderate severity  (Time typically 30 minutes)

  • Detailed history
  • Detailed examination
  • Medical decision making of low complexity

99204  – Presenting problem(s):  Moderate to high severity (Time typically 45 minutes)

  • Comprehensive history
  • Comprehensive examination
  • Medical decision making of moderate complexity

99205 – Presenting problem(s):  Moderate to high severity (Time typically 60 minutes)

  • Comprehensive history
  • Comprehensive examination
  • Medical decision making of high complexity

As we can see from above there are four levels of medical decision making.

  1. Straightforward
  2. Low complexity
  3. Moderate complexity
  4. High complexity

 

Most practitioners and lay people can spot a comprehensive history and examination.  There are a few factors that go into medical decision making. 

 

  1. Number of Diagnoses: minimal, limited, multiple or extensive
  2. Amount and or complexity of Data to be reviewed (record review): minimal, limited, moderate or extensive
  3. Risk of complications and or morbidity or mortality: minimal, low, moderate or high.

 

Two of the three above components must be met to qualify for a given level of complexity.

 

So if you have 3 Diagnoses and you review records for 2 hours one would think you have high complexity.  The problem as I see it is that the terms used such as extensive and moderate or multiple are undefined.