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ADVISORY 2004-06

SUBJECT: Billing for Commission Specific Services, CPT Codes and Modifiers Including Return to Work and Evaluation of Medical Care Examinations

The Texas Workers' Compensation Commission (the Commission) provides direction concerning Commission specific services, CPT codes and modifiers as found in Rule 134.202 (e), Medical Fee Guideline (2002 MFG) that became effective on August 1, 2003.

Use of Commission Specific CPT codes and modifiers
Two Commission Specific Services, Outpatient Medical Rehabilitation Programs and Chronic Pain Programs, use "unlisted" CPT codes. This means that the unlisted CPT codes could be used for those Commission Specific Services and for services that are not specifically listed in other AMA CPT codes. The statement in Rule 134.202(e)(9), "HCPs billing professional medical services shall utilize the following modifiers, in addition to the modifiers prescribed by the Medicare policies required to be used in subsection (b) of this section, for correct coding, reporting, billing, and reimbursement of the procedure codes" is intended to advise health care providers (HCP) that there will be circumstances when both sets of modifiers would be used. When an unlisted CPT code is used for a Commission Specific Service, Commission modifiers should be used in addition to any modifiers required by Medicare policy for that CPT code. When an unlisted CPT code is used for other than Commission Specific Services, Commission modifiers should not be used.

Rule 134.202(e)(9) lists the Commission modifiers that are used in the MFG. The use of Commission modifiers is required for proper coding of the Commission Specific Services listed in Rule 134.202(e). While the Commission modifiers are required for Commission Specific Services, these modifiers should not be used when coding other services. As an example, the Commission modifier "WP" should not be used when billing for a non-Commission Specific Service such as an X-ray or a laboratory test where there is no technical/professional division of reimbursement. Non-Commission Specific Services are billed in accordance with Medicare billing policies.

In addition, the 1996 Medical Fee Guideline prescribed the use of modifiers that are not used in the 2002 MFG. As an example, "L" modifiers were used when coding MMI/IR examinations by designated doctors and required medical examination (RME) doctors conducted under the 1996 MFG. The "L" modifiers are not part of the 2002 MFG and must not be used when coding MMI/IR examination under the current MFG.

Billing for Return to Work (RTW) and/or Evaluation of Medical Care (EMC) examinations
A carrier may request a doctor to perform an examination of the injured employee to determine the ability of the injured employee to return to work, to evaluate the medical care of the employee, or both. If the carrier asks, in a single request, for the doctor to both evaluate the medical care and to determine the ability of the injured employee to return to work, the doctor may bill and be reimbursed for each evaluation, both of which occurred in a single examination. In such cases, the doctor may use modifier "59" to indicate that the services performed to complete the carrier's request were distinct or independent, but appropriate under the circumstances.

Signed this 12th day of May, 2004

Richard F. Reynolds, Executive Director

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