9 payments - blacked out

0232T-RT Claims Administrator denied code
with rationale “ Included in another
billed procedure.”
Claims Administrator denied code with rationale “ Included in another billed procedure.”
UR Determination dated 09/02/2015 received certified 1PRP injection between 8/27/2015 and 8/27/2016.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Documentation dated 9/2/2015 is contract in nature.
0232T has a listed Multiple procedure indicator: “0.” Multiple Procedure Payment adjustment is not applicable.
0232T Reflects Zero Value under OMFS. As such, 0232T is a By Report Code and reimbursement is based on one of the
following: contractual agreement, documented paid cost, or the Providers usual and customary fee.
Assigned Status Code for 0232T is ‘C.”
§ 9789.12.3 Status Codes C, I, N and R
o(a) Except as otherwise provided in this fee schedule, for physician and non-physician practitioner services billed using Current
Procedural Terminology (CPT) codes, the RVUs listed in the Centers for Medicare and Medicaid Services (CMS’) National
Physician Fee Schedule Relative Value File will be utilized regardless of status code.
o(b) When procedures with status indicator codes C, N, or R, do not have RVUs assigned under the CMS’ National Physician
Fee Schedule Relative Value File, these services shall be reimbursed By Report.
Review of the operative report, services were performed and documented.
Opportunity for Claims Administrator to Dispute letter sent on 1/25/2016. A response from Claims Administrator was not
received for this review.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for the billed code 232T-
RT
.
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.”
Provider seeking additional remuneration for 0232T-RT and 0232T –LT Platelet Plasma Injection service performed on Injured
Worker 05/28/2015.
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.”
UR Determination received certified 1PRP injections to bilateral knees between 4/25/2015 and 8/28/2015.

0232T has a listed Multiple procedure indicator: “0.” Multiple Procedure Payment adjustment is not applicable.
0232T Reflects Zero Value under OMFS. As such, 0232T is a By Report Code and reimbursement is based on one of the
following: contractual agreement, documented paid cost, or the Providers usual and customary fee.
A contract agreement not received for this review.
Assigned Status Code for 0232T is ‘C.”
§ 9789.12.3 Status Codes C, I, N and R
o(a) Except as otherwise provided in this fee schedule, for physician and non-physician practitioner services billed using Current
Procedural Terminology (CPT) codes, the RVUs listed in the Centers for Medicare and Medicaid Services (CMS’) National
Physician Fee Schedule Relative Value File will be utilized regardless of status code.
o(b) When procedures with status indicator codes C, N, or R, do not have RVUs assigned under the CMS’ National Physician
Fee Schedule Relative Value File, these services shall be reimbursed By Report.
Review of the operative report, services were performed and documented.
Opportunity for Claims Administrator to Dispute letter sent on 11/12/2015. A response from Claims Administrator was not
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for the billed code 0232T-
RT and 0232T-LT.
20680 Reimbursement for CPT code
20680 was less than expected by the
Provider.
Reimbursement for CPT code 20680 was less than expected by the Provider.
Total billed charges for Hospital Outpatient Services = $11165.03.
This service has a status indicator of “T” and has the highest reimbursement rate of the services provided therefore
reimbursement is to be made at 100% of the allowable amount.
Provider’s conversion factor = 80.44959612.
Provider contract indicates at 5% reduction from OMFS amounts.
Hospital based outpatient surgical center reimbursement increased by 22%.
Based on the OPPS reimbursement set based on the following calculation:
20680 = 23.2928*80.44959612*1.22*.95= $2171.85

20680 The Claims Administrator
denied service with the following
rational: “Service not paid under
OPPS.
Authorization signed by the Claims Administrator on 05/27/2015 indicates approval for “Hardware removal of left
elbow.”Operative note reflects services performed and not in conjunction with an Emergency Room Visit. CCR § 9789.33, For
services rendered on or after September 1, 2014, Status Indicators; “S”, “T”, “X”, or “V”, “Q1,”Q2,” or “Q3” must qualify for
separate payment.” must qualify for separate payment. APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). Based on the aforementioned documentation and guidelines,
reimbursement is indicated for 20680
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”
Provider seeking remuneration for 20680 Removal of Support Implant, Payment Status Indicator “Q2,” provided to Injured
Worker on 09/15/2015.
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”
Authorization signed by the Claims Administrator on June 30, 2015 indicates approval for “Right ankle hardware removal.”
CCR § 9789.33, for services rendered on or after September 1, 2014, Status Indicators; “S”, “T”, “X”, or “V”, “Q1,” Q2 ,” or
“Q3” must qualify for separate payment .”
Provider billed code 20680 along with 73600 and 76000.
Operative note reflects services performed and not in conjunction with an Emergency Room Visit.
APC relative weight x adjusted conversion factor x 1.212 workers’ compensation multiplier, pursuant to Section 9789.30(aa).
Opportunity for Claims Administrator to Dispute sent 2/26/2016. A response from Claims Administrator was not received for
this review.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 20680

23412 and 23120 Claims Administrator denied
services with“ Pre-authorization
required, reimbursement
denied.Visit limit has been reached”
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider is dissatisfied with reimbursement of codes 23412 and 23120 performed on date of service
11/18/2015.
Claims Administrator denied services with“ Pre-authorization required, reimbursement denied.Visit limit has been reached”
Utilization Review Determination of Appealed Request(s) dated 10/29/2015 documents: “specific description of the appealed
medical treatment service approved, if any:
(R) shoulder arthroscopic acromioplasty
Mumford
Rotator cuff repair
Physician’ s Operative Report documents right shoulder arthroscopic procedure converted to an open procedure
along with acromioplasty.
Title 8, California Code of Regulations Chapter 4.5, Division of Workers’ Compensation Subchapter 1 Administrative Director -
Administrative Rules Article 5.3 Official Medical Fee Schedule -Hospital Outpatient Departments and Ambulatory Surgical
Centers: Section 9789.33. Determination of Maximum Reasonable Fee Hospital Outpatient Department Services that are:
Surgical procedures; Emergency Room Visits; or services that are an integral part of the surgical procedure or emergency room
visit: For services rendered on or after September 1, 2014: APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative weight by date of service.
Opportunity for Claims Administrator to Dispute sent on 6/6/2016. A response was not
PPO contractual agreement not submitted for review.
Based on information and guidelines, reimbursement for codes 23412 and 23120 is warranted.

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”
Provider seeking remuneration for codes 24357-59 and 20610-59 performed on 11/23/2015
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”
As pair codes exist between reimbursed code 64718/24357 and 24357/20610, modifier indicator column
shows ‘1’ which states that if an approved modifier is appended to the column ‘2’ code, and documentation is submitted to
support billed codes then the edit may be overridden.
Documentation submitted for review included Authorization for Shoulder Arthroscopy for Rotator
Cuff Synd NOS between dates 12/30/2015 and 01/30/2016. Also included was Provider ’s Operative Report for Procedure date
January 25, 2016.
Documentation to support date of service 11/23/2015 was not included with review.
Based on lack of documentation to support billed codes, reimbursement of 24357-59 and 20610
-59 is Upheld

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.
Provider seeking reimbursement of codes 27425, 29877-59, 29874-59 and 20610-59 performed on date of service 02/01/2016.
Claims Administrator reimbursed CPT code 29875 in the amount $191.11 and denied all other services billed.
Submitted authorization dated December 23, 2015 verifies “Left knee lateral release has been CERTIFIED upon peer review
report”
Provider’s Operative Report submitted documents procedure performed:
1.Left knee arthroscopy, arthroscopic patellar chondroplasty
2.Arthroscopic synovectomy
3.Percutaneous lateral retinacular release
4.Injection Marcaine 25%, 20 ml, plus Toradol 30 mg.
Further in the Provider’s Operative Report states “Through a standard anterolateral portal, the Storz 5-
mmm, 30-degree arthroscope was inserted.” Under Operative Arthroscopy, Provider documents “a percutaneous lateral release
was then performed using Metzenbaum scissors. A 90-degree patellar tile test was possible post-release, and flexion-extension
tracking demonstrated centralization in the trochlea.”
Billed code 27425: Lateral retinacular release, open
Documentation does not support an “open” procedure was performed.
Parenthetical Guidelines specific to 27425: For arthroscopic lateral release, use 29873.
NCCI edits exist between procedure performed code 29873 and all other billed codes 29877, 29874, 29875 and 20610 which are
not separately reimbursable per Medicare correct coding guidelines.
Based on aforementioned documentation and guidelines, additional reimbursement is recommended for CPT 29873 only.
PPO contract not submitted for IBR

29822-59,29826
-59
Provider is dissatisfied with denial of codes 29822-59 and 29826-59
Based on the NCCI edits, generally code 29824 and 29822 are generally not reported together either. However, Modifier
Indicator column shows ‘1’, there may be occasions where both codes are payable. Provider billed 29822-59, which is an
appropriate override modifier for the NCCI edit.
Based on review of the operative report, Provider documents 29822-59, Arthroscopy, shoulder, surgical; debridement, limited,
as a distinct procedure. Therefore, reimbursement for CPT 29822-59 is warranted.
CPT 29826-59 was also denied after having been approved by Claims Administrator’s Utilization Review as documented in the
Certification Recommendation letter received. CPTs approved in the letter from the Utilization Review include: 29826, 29827,
29807, 23430 and 29424. Claims Administrator approved 29826 prior to the procedure and then denied it as bundled with 23412
which was reimbursed. Since CPT 23412 was reimbursed, no reimbursement for 29826 is recommended.
PPO Contract reviewed shows a 6% discount is to be applied to the reimbursement.

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”
Provider seeking remuneration for 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface
(mumford procedure) for date of service 05/29/2015. SBR indicates a dispute amount of $2,220.96.
Opportunity to Dispute communicated to Claims Administrator on 01/28/2016 , response not yet received.
Operative Report, page 2, the Provider indicates, “distal 1cm clavicle was excised.”
Contractual Agreement not submitted for IBR; unknown if >1cm rem oval of clavicle is required for reimbursement. As the
size of the excised piece is not a CPT requirement, reimbursement is indicated
for 29824 and is subject to Endoscopic MPPR reimbursement.
§9789.16.5 (d)Determining Maximum Payment for Endoscopies (e) Multiple Procedures of Equal Value:
If two or more multiple surgeries are of equal value, rank them in descending dollar order billed and base payment on the
percentages listed above (i.e., 100 percent for the first billed procedure, 50 percent for the second, etc.)
EOR 07/09/2015 reflects $4,442.31 reimbursed for Primary Arthroscopic Procedure.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 29824

29824 and 29822
-
59
ISSUE IN DISPUTE: Provider seeking remuneration of billed codes 29824 and 29822 erformed on date of service
12/07/2015.
Claims Administrator’s reimbursement rationale of CPT 29824 “H01: Priced according to state regs out-patient facility
schedule.” Claims Administrator denied 29822 with rationale “Service/item included in the value of other services per CCI
edits.”
Pair code does exist between the two codes with edit description: More extensive procedure.
29824 / 29822 -More extensive procedure
Per Medicare NCCI Policy Manual on More Extensive Procedures : The CPT Manual often describes groups of similar codes
differing in the complexity of the service. Unless services are performed at separate patient encounters or at separate anatomic
sites, the less complex service is included in the more complex service and is not separately
reportable.
29822: Arthroscopy, shoulder, surgical; debridement, limited
Per Medicare NCCI Policy Manual: E. Arthroscopy -With the exception of the knee joint, arthroscopic debridement should not
be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter.
Reimbursement of 29822 is not warranted.
PPO contract received states: “Outpatient Services percent discount. 10% Discount off of the rate or fee established by the
applicable Official Medical Fee Schedule of the applicable state provided to a Workers’ Compensation Claimant. 18% Discount
off usual billed charges for all other services. Notes: The reimbursement amounts will be the lesser of charges, the negotiated
rates or the applicable official Medical Fee Schedule rate or fee (when applicable to workers’compensation beneficiary), and as
mandated by the Hospital Official Medical Fee Schedule(s).”
Provider billed a total of $14,019.09 on a UB-04 with Bill Type 131, Hospital Outpatient.
Section 9789.33. Determination of Maximum Reasonable Fee: (a) In accordance with section 9789.32, the maximum allowable
payment for outpatient facility fees for hospital emergency room services, surgical services, or for Facility Only Services
performed at a hospital outpatient department, or for surgical services performed at an ambulatory surgical center shall be
determined based on the following:
For services rendered on or after September 1, 2014: APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative
weight by date of service.


58.6059 x 83.44 x 1.212 = 5,926.77
x 90% = $5334.10

$14,019.09 x 82% = $11,495.65

Opportunity for Claims Administrator to Dispute sent on 6
/1/2016. A response from
Claims Administrator was not received for this review.

Based on Outpatient guidelines and contractual agreement, additional reimbursement is
due for code
29824
29824 and 29822-59 Claims Administrator’s
reimbursement rationale of CPT
29824 “H01: Priced according to
state regs out-patient facility
schedule.” Claims Administrator
denied 29822 with rationale
“Service/item included in the value
of other services per CCI edits.”
ISSUE IN DISPUTE: Provider seeking remuneration of billed codes 29824 and 29822 performed on date of
Service12/07/2015.
Claims Administrator’s reimbursement rationale of CPT 29824 “H01: Priced according to state regs out-patient facility
schedule.” Claims Administrator denied 29822 with rationale “Service/item included in the value of other services per CCI
edits.”
Pair code does exist between the two codes with edit description: More extensive procedure.
29824 / 29822 -More extensive procedure
Per Medicare NCCI Policy Manual on More Extensive Procedures: The CPT Manual often describes groups of similar codes
differing in the complexity of the service. Unless services are performed at separate patient encounters or at separate anatomic
sites, the less complex service is included in the more complex service and is not separately
reportable.
29822: Arthroscopy, shoulder, surgical; debridement, limited
Per Medicare NCCI Policy Manual: E. Arthroscopy -With the exception of the knee joint, arthroscopic debridement should not
be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter.
PPO contract received states: “Outpatient Services percent discount. 10% Discount off of the rate or fee established by the

applicable Official Medical Fee Schedule of the applicable state provided to a Workers’Compensation Claimant. 18% Discount
off usual billed charges for all other services. Notes: The reimbursement amounts will be the lesser of charges, the negotiated
rates or the applicable official Medical Fee Schedule rate or fee (when applicable to workers’compensation beneficiary), and as
mandated by the Hospital Official Medical Fee Schedule(s).”
Provider billed a total of $14,019.09 on a UB-04 with Bill Type 131, Hospital Outpatient.
Section 9789.33. Determination of Maximum Reasonable Fee: (a) In accordance with section 9789.32, the maximum allowable
payment for outpatient facility fees for hospital emergency room services, surgical services, or for Facility Only Services
performed at a hospital outpatient department, or for surgical services performed at an ambulatory surgical center shall be
determined based on the following:
For services rendered on or after September 1, 2014 : APC relative weight x adjusted conversion factor x 1.2
12 workers’ compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative
weight by date of service.

58.6059 x 83.44 x 1.212 = 5,926.77
x 90% = $5334.10
$14,019.09 x 82% = $11,495.65
Opportunity for Claims Administrator to Dispute sent on 6/1/2016. A response from Claims Administrator was not received for
this review.
Based on Outpatient guidelines and contractual agreement, additional reimbursement is due for code 29824.
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”
Provider seeking remuneration of billed codes 29848 -LT, 64718-LT, 26055-LT, and 20550-59LT
performed on date of service 12/02/2015
Claims Administrator denied all codes with rationale “diagnosis was invalid for the date(s) of service reported”
Authorization dated 11/12/2015 from Claims Administrator documents “The purpose of this letter is to confirm authorization for
the requested medical services noted below:
1.Wrist endoscopy/surgery 29848
2.Revise ulnar nerve at elbow 64718
3.Incise finger tendon sheath 26055
4.Physical Therapy Quantity: 8(2x4 left long finger)
5.Physical Therapy Quantity: 8 (2x4 left elbow)
6.Physical Therapy Quantity: 8 (2x4 left wrist)
*Documentation shows date range between 11/12/2015 and 1/11/2016.
*Diagnosis not documented on authorization.

Authorization dated 11/12/2015 is contract in nature.
Provider submitted Operative Report which documents services performed on the injured worker’s left wrist and left
finger.Report included diagnosis: Left carpal tunnel syndrome, left cubital tunnel syndrome, left long finger trigger digit and left
ring finger trigger digit.
Ambulatory Surgical Centers surgical procedures, for services rendered on or after September 1, 2014:
APC relative weight x adjusted conversion factor x 0.808 workers’ compensation multiplier, pursuant to Section 9789.30(aa).
Pursuant chapter 4 of the National Correct Coding Initiative Policy Manual for Medicare Services: Injections of local anesthesia
for musculoskeletal procedures (surgical or manipulative) are not separately reportable. For example, CPT codes 20526-
20553(therapeutic injection of carpal tunnel, tendon sheath, ligament, muscle trigger points) should not be reported for the
administration of local anesthesia to perform another procedure.
Opportunity for Claims Administrator to Dispute sent on 4/29/2016. A response was not received for this review.
Based on aforementioned documentation and guidelines, reimbursement of 29848, 64718 and 26055 is warranted.
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.”
Provider is dissatisfied with denial of code 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.”
Provider billed codes 29876 and 29881-51 on a CMS 1500 form.
Based on review ofthe operative report submitted, Provider documents very clear that a medical meniscectomy was performed
along with synovectomies of patellofemoral, medial and lateral compartments.
Claims Administrator was incorrect to deny code 29881-51. Therefore, reimbursement of code 29881 is warranted

29882 Claims Administrator denied code
indicating “Allowance is based on
Utilization Review pre-
authorization”
Provider seeking remuneration for 29882 performed on date of service 10/15/2014
Claims Administrator denied code indicating “Allowance is based on Utilization Review pre-authorization”
Communication dated September 10, 2014 from Claims Administrator to Provider documents “
UR Decision: Approved: Left knee arthroscopy with partial medical meniscectomy, Qty: 1”
Provider’s Operative Report documents Arthroscopic medial meniscal repair, right knee.
compensation multiplier, pursuant to Section 9789.30(aa).
EOR submitted shows a payment of $569.18 for 29882-LT.
Based on aforementioned guidelines and documentation, additional reimbursement of 29882 is warranted.
33249 and 93005 ANALYSIS AND FINDING
ISSUE IN DISPUTE: Provider seeking additional remuneration for 33249 and 93005 performed on 12/03/2015.

Initial EOR does not provide a clear indication for“0.00” reimbursement .Services performed in addition to other services;
$359.07 out of $500,347.68 reimbursed.
Documentation indicates SBR requested; 2ndEOR not received.
CPT Status Indicator, Weight and AMA CPT Code Description:
CPT 33249: S,442.3292 , Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s),
single or dual chamber
CPT 93005: Q3, 0.3732, Electro cardiogram tracing, Electrocardiogram, routine ecg with at least 12 leads; tracing only,
without interpretation and report
Contractual Agreement not submitted for IBR.
CCR § 9789.33 , For services rendered on or after September 1, 2014, Status Indicators; “S”, “T”, “X”, or “V”, “Q1,” Q2,” or
“Q3 ” must qualify for separate payment.” must qualify for separate payment. APC relative weight x adjusted conversion factor x
1.212 workers’ compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative weight by
date of service
Based on the aforementioned documentation and guidelines, additional reimbursement
is indicated for
3
3249 and 93005.
63047-59-51 Claims Administrator was incorrect
to deny code 63047-59-51 and
therefore, reimbursement is
recommended.
Provider is dissatisfied with denial of CPT code 63047-59-51.
Based on the NCCI edits that exist with code 63047, Modifier Indicator is showing ‘1’ as a modifier appended can override the
NCCI Edit with supporting documentation. Modifier -59 is an accepting modifier for this rule per NCCI.
CPT 63047 -Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral
segment; lumbar
Based on review of the operative report page 2 paragraph two, Provider documents “dissection carried down bilaterally to
expose the inferior L3 lamina up the S1 lamina, and dissection was carried out laterally to the edges of the facets.”
Claims Administrator was incorrect to deny code 63047-59-51 and therefore, reimbursement is recommended.

A PPO discount of 5% will be applied as well as the multiple surgical procedures reimbursement Rule #7 Provider is dissatisfied
with denial of CPT code 63047-59-51.
Based on the NCCI edits that exist with code 63047, Modifier Indicator is showing ‘1’ as a modifier appended can override the
NCCI Edit with supporting documentation. Modifier -59 is an accepting modifier for this rule per NCCI.
CPT 63047 -Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral
segment; lumbar
Based on review of the operative report page 2 paragraph two, Provider documents “dissection carried down bilaterally to
expose the inferior L3 lamina up the S1 lamina, and dissection was carried out laterally to the edges of the facets.”
Claims Administrator was incorrect to deny code 63047-59-51 and therefore, reimbursement is recommended.
A PPO discount of 5% will be applied as well as the multiple surgical procedures reimbursement Rule #7
63650 and 63650
-59
EOR indicates DWC Payment
Reduction G1:“The charge exceeds
the Official Medical Fee Scheduled
Allowance.”
Provider seeking 100 % ASC remuneration for 63650 & 63650-59 for date of service 10/13/2015.
EOR indicates DWC Payment Reduction G1:“The charge exceeds the Official Medical Fee Scheduled Allowance.”
CMS 1500 reflects Bill Type “831.”
For services rendered on or after December 1, 2014, section 9789.30, subsections (a) adjusted conversion factor, (e) APC
payment rate, (f) APC relative weight, (j) Facility Only Services,(q) labor

-related share, (r) market basket inflation factor, and (z) wage index, are adjusted to conform to the
Medicare hospital outpatient prospective payment system (HOPPS) final rule of December 10, 2013, the
relative values in the 2014 Medicare Physician fee schedule, and the wage index values in the Medicare
IPPS final rule of August 19, 2013, and associated rules and notices to the IPPS final rule published
In the Federal Register.
For services rendered on or after September 1, 2014 APC relative weight x adjusted conversion factor
X 0.808 workers’ compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b)
For the APC relative weight by date of service.
63650 & 63650-59 are valid codes for date of service 10/13/2015 in accordance with theOMFS.
63650, Status Indicator “S,” not subject to MPPR.
Opportunity for Claims Administrator to Dispute Eligibility sent on 2/29/2016. A response from Claims
Administrator was not received for this review.
Based on the aforementioned documentation and guidelines, additional reimbursement for 63650 &
63650-59 is warranted
63661 x 3 Claims administrator denied codes
Review “No separate payment was
made because the value of the
same day””
Provider is dissatisfied with denial of codes 63661 x 3 units
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””
Operative Report received documents 1 electrode was removed on date of service 5/19/2015.
CCR § 9789.30, subsections (a) adjusted conversion factor, (e) APC payment rate, (f) APC relative weight, (j) Facility Only
Services, (q) labor-related share, (r) market basket inflation factor, and (z) wage index, are adjusted to conform to the Medicare
hospital outpatient prospective payment system (HOPPS) final rule of December 10, 2013, the relative values in the 2014
Medicare Physician fee schedule, and the wage index values in the Medicare IPPS final rule of August 19, 2013, and associated
rules and notices to the IPPS final rule published in the Federal Register.
Per CMS 2014 NCCI Edit Policy Manual: The MUE values for CPT code 63661 (removal of spinal neurostimulator electrode
percutaneous array(s)...) and CPT code 63662 (removal of spinal neurostimulator electrodeplate/paddle(s) placed via laminotomy
or laminectomy...) are one (1). Each code descriptor includes the removal of some or all electrode percutaneous arrays and some
or all electrode plates/paddles for a neurostimulator pulse generator. If a patient has two separate neurostimulator pulse
generators and some or all electrodes are removed for each neurostimulator pulse generator separately, the removal of the
percutaneous array(s) or plate(s)/paddle(s) for the second neurostimulator pulse generator may be reported with modifier 59.

Based on aforementioned guidelines, reimbursement of one (1) unit of 63661 is warranted.
63685 and 76000
-
59
ISSUE IN DISPUTE: Provider seeking additional reimbursement for codes 63685 & 76000 -59 per formed on date
of service 02/16/2016.
The Provider billed the disputed codes on a UB04, with bill type 131, Outpatient services.
Claims Administrator based reimbursement with “Workers Compensation Jurisdictional Fee Schedule Adjustment”
A PPO Contractual agreement not submitted for reviewed.
76000: Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time, other than
71023 or 71034 (eg, cardiac fluoroscopy)
NCCI Policy Manual for Medicare Service: Separate Procedure: If a CPT code descriptor includes the term “separate
procedure”, the CPT code may not be reported separately with a related procedure. CMS interprets this designation to prohibit the
separate reporting of a “separate procedure” when performed with another procedure in
an anatomically related region often through the same skin incision, orifice, or surgical approach.
A CPT code with the “separate procedure” designation may be reported with another procedure if it is performed at a separate
patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area often through a
separate skin incision, orifice, or surgical approach.
20. Fluoroscopy reported as CPT codes 76000 or 76001 should not be reported with spinal procedures unless there is a specific
CPT Manual instruction indicating that it is separately reportable. For some spinal procedures there are specific radiologic
guidance codes to report in lieu of these fluoroscopy codes. For other spinal procedures,
fluoroscopy is used in lieu of a more traditional intraoperative radiologic examination which is included in the operative
procedure. For other spinal procedure codes, fluoroscopy is integral to the procedure.
Documentation submitted does not reflect a “separate procedure”
Reimbursement of 76000-59 is not warranted.
§9789.33 - For services rendered on or after September 1, 2014; APC relative weight x adjusted conversion factor x 1.212
workers’compensation multiplier, pursuant to Section 9789.30(aa).
63685: 237.1326 x $83.31 x 1.212 = $23,943.69

CPT 63685 has a status code “S” procedures.
“S” Procedure or Service, Not Discounted When Multiple . Paid under OPPS; separate APC payment.
Additional reimbursement is warranted for the CPT code 63685

64483- LT Claims Administrator denied codes
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.
Notice of Authorization dated August 17, 2015 from Claims Administrator certified “Left L4 Transforaminal
Epidural Steroid Injection, anesthesia, under fluoroscopic guidance at Galileo Surgery Center. ”
Documentation dated August 17, 2015 is contract in nature.
Provider billed code 64483 along with 72275 on a CMS 1500 with place of service 24.
Provider’s Operative Procedure Report documents Left L4 Transforaminal Epidural Steroid Injection under Fluoroscopy.
Based on guidelines and documentation reviewed, reimbursement of 64483-LT is warranted.
64493 and 64495 Provider is seeking remuneration of code 64493 -50 performed on date of service 02/11/2016. 64495 is not in dispute.
Claims administrator reimbursed denied service indicating on the Explanation of Review “charge is denied as the service was
not authorized”
Communication from Claims Administrator dated January 19, 2016 documents “I am authorizing the request for medical branch
block to test bilateral L4-5 and L5-S1 facet joints. ” Specific date or date range not documented on authorization.
Provider’s Operative Report documents bilateral injections and submitted code 64493 with a modifier
-50. Modifier -50 supports the bilateral procedure and is reimbursed an increase of 150% of the fee schedule of a single code.
9.2183 x 87.33 x 1.21 = 974.09 x 150% = 1461.14 x 93% = $1358.86
Opportunity to Dispute Letter was sent to Claims Administrator on 5/18/2016. A response from Claims Administrator was not

received for this review. Based on information reviewed, additional reimbursement is warranted for code 64493-50.
PPO contract submitted shows a 7% PPO discount is to be applied to reimburse
64493 and 64495 Claims administrator reimbursed
denied service indicating on the
Explanation of Review “charge is
denied as the service was not
authorized”
Provider is seeking remuneration of code64493-50 performed on date of service 02/11/2016.
64495 is not in dispute.
Claims administrator reimbursed denied service indicating on the Explanation of Review “charge is denied as the service was
not authorized”
Communication from Claims Administrator dated January 19, 2016 documents “I am authorizing the r
equest for medical branch block to test bilateral L4-5and L5-S1 facet joints.” Specific date or date range not documented on
authorization.
Provider’s Operative Report documents bilateral injections and submitted code 64493 with a modifier
-50. Modifier -50 supports the bilateral procedure and is reimbursed an increase of 150% of the fee schedule of a single code.
9.2183 x 87.33 x 1.21 = 974.09 x 150% = 1461.14 x 93% = $1358.86
Opportunity to Dispute Letter was sent to Claims Administrator on 5/18/2016. A response from Claims Administrator was not
Based on information reviewed, additional reimbursement is warranted for code 64493-50.
PPO contract submitted shows a 7% PPO discount is to be applied to reimbursement

64510 Claims Administrator denied
service indicating on the
Explanation of Review “ This
service appears to be unrelated to
the patients diagnosis”
Provider billed diagnosis G90.511 on UB-04 with bill type 837.
G90.511: Complex regional pain syndrome of right upper limb.
Provider’s Operative Report documents “Stellate Ganglion Block “fluoroscopy was used to identify the right C-6transverse
process” and “spinal needle was advanced toward the medial aspect of the C-6 transverse process...”
RFA dated 08-28-2015 documents “Procedure Requested: Stellate Ganglion Block on the Right Side under Fluoroscopy and
monitored anesthesia care to be done at Oasis Surgery Center”
Communication from Claims Administrator to Provider dated September 25, 2015 showing authorization for “Approved Service
Description: Right Stellate Ganglion Block under Fluoroscopy and monitored anesthesia care”
Communication from Claims Administrator dated September 25, 2015 is contract in nature.
Based on information reviewed and guidelines, reimbursement of 64510 is warranted.
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”
Provider seeking remuneration of 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic performed on
date of service 08/03/2015
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”
64520 has status indicator T -Procedure, Multiple Reduction Applies. Paid under OPPS; Separate APC payment.
Status Code Indicators: For services rendered on or after September 1, 2014-“S”, “T”, “X”, or “V”, “Q1”, Q2”, or “Q3”. Status

code indicators “Q1”, “Q2”, and “Q3” must qualify for separate payment.
Provider billed code 64520 along with J8499, J2250 and J3010 on a UB04 Type of Bill 131.
Authorization submitted documents “Left lumbar Paravertebral Sympathetic Block with IV Sedation; medically necessary”
dated July 13, 2015.
Final Report submitted documents Left lumbar paravertebral sympathetic block performed on date of service 8/3/2015.
For services rendered on or after September 1, 2014 : APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative.
Based on documentation and guidelines, reimbursement of 64520 is warranted
indicating “no separate payment
was made because the value of the
same day”
Provider billed code 64718-59 along with 25115 which was reimbursed.
As a pair code edit does exist with codes 64718 and 25115, modifier indicator column shows a ‘1’ which states that if an
approved modifier is appended to the column 2 code, and documentation supports billed code, then the edit may be overridden.
Provider appended approved modifier -59 to column 2 code 64718
Provider’s Operative Report supports 64718 with modifier -59, a separate incision/excision was made.
Based on documentation and guidelines, reimbursement of 64718-59 is warranted.
64721
-
59
,
RT
Based on review of the case file the followi
ng is noted:

ISSUE IN DISPUTE
:
P
rovider seeking remuneration for 64721
-
59

-
RT services
submitted for date of service 11/1
9/2015.

E
OR
’
s indicate s
ervices denied per NCCI edits.

Opportunity to Dispute
c
ommunicated with the Claims Administrator on 06/08/2016:
response not yet
received
.

Contractual Agreement not
submitted
for IBR.

A
uthorization signed by the Claims Administrator reflects anatomical sites
r
elating to right
hand and right elbow.

Services billed utilizing CMS 1500.

NCCI edits indicate CPT 64721 is a column
2 code to (billed
services
) 64708.

AMA CPT indicates
“
Modifier 59 is used to identify procedures/services, other than E/M
services, that are not normally reported to
gether, but are appropriate under the circumstances.
Documentation must support a different session, different procedure or surgery,
different
site
or organ system, separate incision/excision, separate lesion, or separate injury (or area of

injury in exte
nsive injuries) not ordinarily encountered or performed on the same day by the
same individual.
”
(
Emphasis
a
dded)

Operative report
r
eflects 64721
and 64708 procedures were
performed
on different
anatomical sites;
right
wrist
median nerve
,
right
elbow
interosseous nerve branch of the
rad
ial nerve.

CMS 1500
appropriately
reflects modifier
-
59.

64721
Physician Fee Schedule Relative Value File refle
cts service is subject to MPPR and
will be reflected in the
reimbursement
table on page 4.

B
ased on the
aforementioned
documentation and
guidelines

,
reimbursement
is
indicated for 64721.
72070 and
72110
Claims administrator denied codes
Review “The charge was denied as
the report/documentation does not
indicate that the procedure was
performed.”
Provider is dissatisfied with denial of codes 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.”
Provider documents in the report submitted that the worker was injured when a co-worker fell on top of her and she landed on
her back and neck areas. Also noted in the report, medical necessity: lumbar spine 5 views –standard claim of pain LS area;
thoracic spine 2 views claim of pain T spine area. Both with Findings ‘pending’. Diagnoses: contusion –back lower (922.31);
contusion –back upper (922.33)
Based on information reviewed, Provider does document procedures were performed during the new patient exam and therefore,
reimbursement of codes 72070 and 72110 is warranted.

72070 and 72110 ISSUE IN DISPUTE:
Provider is dissatisfied with denial of codes 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.”
Provider documents in the report submitted that the worker was injured when a co-worker
fell on top of her and she landed on her back and neck areas. Also noted in the report, medical necessity: lumbar spine 5 views –
standard claim of pain LS area; thoracic spine 2 views claim of pain T spine area.
Both with Findings ‘pending’. Diagnoses: contusion –back lower (922.31); contusion –back upper (922.33)
Based on information reviewed, Provider does document procedures were performed during the new patient exam and
therefore, reimbursement of codes 72070 and 72110 is warranted.
72275-26-59 Claims Administrator denied code
Provider is dissatisfied with denial of code 72275-26-59
Claims Administrator denied code indicating on the Explanation of Review “The appended modifier code is not appropriate

Review “The appended modifier
code is not appropriate with the
service billed”
with the service billed”
72275 -Epidurography, radiological supervision and interpretation
Authorization received dated 03/18/2015 states “Cervical Epidural Steroid Injection under Anesthesia with X-ray and
Fluoroscopic Guidance is medically approved by the utilization review nurse”
CPT Guidelines state “Fluoroscopy (for localization) may be used in the placement of injections reported with 62310-62319,
but is not required. If used, fluoroscopy should be reported with 77003. For epidurography, use 72275”
Provider submitted an Operative Report along with a separate Epidurogram report which is required for code 72275.
Based on UR authorization and CPT guidelines, reimbursement of 72275 is warranted.
PPO contract received shows a 15% discount is to be applied to reimbursement
73721 The Claims Administrator denied
service as unauthorized.
Provider seeking remuneration for 73721 MRI joint of l0wr extremity w/o dye performed on 05/06/2015.
The Claims Administrator denied service as unauthorized.
Submitted Contractual Agreement, “Appendix A/B” reflects “95%” OMFS.
Authorization, dated “April 27, 2015,” signed by Claims Administrator states the following service and CPT Code
as “medically necessary” :o MRI Left Hip 73721
CCR § 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
and Safety Code, and a contracting agent, employer, or carrier contract for
reimbursement rates different from those in the fee schedule , the medical fee schedule for that health care provider or health
facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
The aforementioned ‘April 27, 2015,” documentation is contractual in nature. As such, the contractual agreement applies
pursuant to LC § 5307.11 and reimbursement is warranted.

reimbursement for 76942 stating:
“Incidental to Procedure,” and
“rarely, if ever, performed.”
Provider seeking remuneration for 76942 Ultrasonic guidance utilized for Pain Pump Refill needle placement (eg, biopsy,
aspiration, injection, localization device), imaging supervision and interpretation services performed on 04/22/2015 &
05/27/2015.
The Claims Administrator denied reimbursement for 76942 stating: “Incidental to Procedure,” and “rarely, if ever, performed.”
Included for IBR is a dictated Secondary Physician Progress Report.
CPT 76942 code description includes “imaging supervision and interpretation.”
A Secondary Physician Progress Report reflecting dates of service 04/22/2015 and 05/27/2015 reviewed , indicating Ultrasonic
Guidance was necessary due to “hypermobility of pump.”
Three 3 x 4 inch print images (copies) of the ultrasounds were reviewed reflecting dates of service 04/22/2015 and 05/27/2015.
Medicare Regulations Revision. 2932, 04-18-14, Chapter 13, section 20.1 for “Professional Component” (PC) states: “The
interpretation of a diagnostic procedure includes a written report.”
A separate copy of the Ultrasonic interpretation was included and reviewed reflecting dates of service 04/22/2015 and
05/27/2015.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 76942.
indicating “The charge was denied
as the report/documentation does
Provider seeking remuneration for 90792, Psychiatric diagnostic evaluation with medical services for date of service 06/24/2015
Claims Administrator denied code indicating “The charge was denied as the report/documentation does
not indicate that the service was performed”

not indicate that the service was
performed”
Beginning in 2013, there are two new codes to use to report psychiatric diagnostic procedures: 90791 for evaluations that do not
include medical services, and code 90792 for evaluations that do include medical services. "Medical services" consist of medical
activities or consideration, such as performing additional elements of the physical examination, considering writing a
prescription, ordering laboratory or imaging
examination(s), and considering modifying psychiatric treatment based on medical comorbidities.
Documentation submitted for review supports billed code 90792.
Reimbursement of 90792 is warranted.
PPO contract not submitted for review.
EOR received reflects a 5% PPO discount to be applied to reimbursement.
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
Provider seeking remuneration for 90792, Psychiatric diagnostic evaluation with medical services for date of service
06/24/2015
Claims Administrator denied code indicating “The charge was denied as the report/documentation does not indicate that the
service was performed”
Beginning in 2013, there are two new codes to use to report psychiatric diagnostic procedures: 90791 for evaluations that do not
include medical services, and code 90792 for evaluations that do include medical services. "Medical services" consist of medical
activities or consideration, such as performing additional elements of the physical examination, considering writing a
prescription, ordering laboratory or imaging examination(s), and considering modifying psychiatric treatment based on medical
comorbidities.
Documentation submitted for review supports billed code 90792.
Reimbursement of 90792 is warranted.
PPO contract not submitted for review.
EOR received reflects a 5% PPO discount to be applied to reimbursement.

Review “Documentation does not
support prolonged services.”
Provider is dissatisfied with denial of CPT 90833.
Claims Administrator denied code indicating on the Explanation of Review “Documentation does not support prolonged
services.”
Provider’s Progress Report (PR-2) submitted documents 90833 (including 20 minutes of psychotherapy)
Based on CPT Guidelines 2014, in reporting psychotherapy codes, choose the code closest to the actual time (ie, 16-37 minutes
for 90832 and 90833).
90833 –Psychotherapy, 30 minutes with patient and/or family member when performed with an valuation and management
service. (list separately in addition to the code for primary procedure). Use 90833 in conjunction with 99201-99255
Explanation of Review shows a 5% discount was applied to reimbursement. A 5% discount shall
be applied.
Review “CPT code submitted is
based on service time and
documentation does not support the
time spent on this procedure”
Provider is dissatisfied with denial of code 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 -Psychotherapy, 60 minutes with patient and/or family member
Psychiatric PTP Progress Report and Chart Note submitted states “60 min face to face”for code 90837.
EOR received from Claims Administrator shows a payment was submitted to Provider in the amount $142.97for code 90837
after this dispute had been filed.
Based on information reviewed, reimbursed was warranted for code 90837 and therefore, Claims Administrator is responsible

for the IBR application fee in the amount of $195.00
Review “CPT code submitted is
based on service time and
documentation does not support the
time spent on this procedure”
”
Final EOR submitted states two dates of service reviewed: 5/18/2015 and 6/2/2015. Per CCR, title 8 section 9792.5.8, Provider
is to submit final EOR submitting second review of codes billed.
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”
Claims Administrator denied 90837 on both dates of service as “charge exceeds the Official Medical Fee Schedule”
UR Determination dated May 06, 2015 authorized 6 psychotherapy treatments between 4/20/2015 and 7/3/2015.
Specific CPT codes 90837 and 96101 submitted on RFA.
Based on information reviewed, reimbursement is warranted for code 90837 on both dates of service.
EOR submitted shows a 5% PPO discount to be applied to reimbursement
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
Provider seeking remuneration 90837 Psychotherapy, 60 minutes x 4 units for dates of service: 02/20/2014, 03/16/2014,
03/20/2014 and 04/03/2014.
Claims Administrator denied 90837 service stating: “Per CCI Edits, the value of this procedure is included in the value of the
comprehensive procedure.”

procedure.” 90837, is paired to billed code 90901, biofeedback training by any modality.
NCCI edits reveal 90901 is Colum 1 Code when billed with Colum 2 Code, 90901.
Under certain circumstances, the paired codes in question may be unbundled with the use of modifier
-59. NCCI Edits state,“Modifier 59: Modifier 59 is an important NCCI-associated modifier that is often used incorrectly. For the
NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient
encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more
procedure codes. The CPT Manual defines modifier 59 as follows: Modifier 59: ‘Distinct Procedural Service: Under certain
circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M
services performed on the same day. Modifier 59 is used to identify procedures/services other than E/M services that are not
normally reported together, but are appropriate under the circumstances. Documentation must support a different session,
different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or
area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However,
when another already established modifier is appropriate, it should be used rather than modifier 59.’ ”
Documentation of 02/20/2014, 03/16/2014, 03/20/2014 and 04/03/2014. Patient encounters included
one PR-2 report listing the dates in question. Documentation indicates “time spent in session 60 min,” for all four listed dates.
Separately Identifiable service, over and above 90837 60 min service could not be identified.
Claims Administrator Reimbursed Provider for 90901 on all dates of service.
Only 90837 services are clearly identified in documentation.
Based on the aforementioned guidelines, reimbursement is recommended for 4units of 90837.
Contractual Agreement requested on 09/24/2013 not yet received during IBR. As such, reimbursement rate could not be
identified. OMFS will be utilized to calculate reimbursement.
EOR reflects Provider Reimbursed 4 units of 90901 @ $58.24= $232.96
Authorization for services dated February 25, 2014 states “Cognitive Behavioral Sessions,” and Biofeedback Therapy Sessions,”
X6 as “Certified.”
Recommend reimbursement for 90876, “Individual psychophysiological therapy incorporating biofeedback training by any
modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive
psychotherapy); 45 minutes,” as code best describes authorized se

services indicating “resubmit with
indicated documentation as soon as
possible.”
Provider seeking remuneration for 90880 Hypnotherapy services submitted for dates of service 09/30/2015-10/28/2015.
The Claims Administrator denied services indicating “resubmit with indicated documentation as soon as possible.”
Authorization dated August 20, 2015 “Approved” 90880 for 1session a week x 8 weeks between 08/13/215-12/30/15 and
signed by Claims Administrator.
Provider billed code 90880 on the same dates of service as 90853.
Documentation of 90880 services reflected on Psychological Assessment Services “progress notes” documents “Procedure
codes 90880 & 90853 were provided on the same day but not in conjunction during the same session.”
NCCI Edit pair code exists between billed codes 90880 and 90853. Modifier Indicator column shows ‘0’which states a modifier
is not appropriate and services represented by code combination not paid separately
Based on the aforementioned documentation, authorized services for 90880 is not indicated
.
95886 and 95913 Claims Administrator denied
reimbursement indicating “charge is
denied as the service was not
Authorized during the Utilization
Review process
.
Communication to Provider from Claims Administrator dated November 10, 2015 documents “Approved Service Description:
EMG Left Upper Extremity, NCV Left Upper Extremity, EMG Right Upper Extremity” between date of service 11/03/15-
02/29/2016.
Not approved by Utilization Review NCV Right Upper Extremity.
Documentation dated November 10, 2015 is contract in nature and therefore services were approved.
Provider submitted documentation supporting nerve and muscle tests conducted on date of
service 12/2/2015

95913 ANALYSIS AND FINDING
ISSUE IN DISPUTE: Provider seeking additional remuneration for 95913, 13 or more Nerve Conduction Studies,
submitted for date of service 09/24/2014.
Opportunity to Dispute Eligibility communicated with the Claims Administrator on 04/13/2016; response received
04/26/2016. The Claims Administrator indicated the Left Median Sensory and Left Median Radial is “not related to the work
comp injury of the right upper extremity,” and the left hand comparison studies were “ not counted.”
Referral, Signed by the QME on 09/09/2014, indicates Right Upper Extremity EMG/NCV.
Nerve Conduction Study Results indicate the following sensory nerves tested on the Right Upper Extremities:1.Ulnar Nerve –
Right
To 5th
digit
Dorsal Cutaneous 2. Median Nerve –Right
Left Median not authorized 3.RadialNerve –Right
Total Sensory Nerves = 3
Nerve Conduction Study Results indicate the following motor nerves tested on the upper extremities: 1.Radial Motor -Right2.
Median Motor –Right 3. Ulnar Motor –Right
Total Motor Nerves Tested = 3
Documentation for Nerve Conduction Study reflects 6 nerves studied
 Provider’s Consultation Report indicates “peak latency differencesn” were “noted on comparison” resulting
in a diagnosis of “ carpel tunnel syndrome based on the comparison studies.”Reimbursement is indicated for the comparison
studies 5 Studies, R. Median, Ulnar and bilaterally.
Based on the aforementioned documentation and the review of the CPT descriptor, CPT code Reimbursement
is recommend for 95912, Nerve conduction test 11-12 studies,
and is not
indicated for 95913.

with indication “The testing results
are needed in order to review this
charge”
Claims Administrator denied code with indication “The testing results are needed in order to review this charge”
Submitted for review was the Lower Extremity Study Electrodiagnostic Examination Report showing results for
12 sensory and motor nerves tested.
CPT Assistant for 95913 -A nerve conduction study is counted only once when multiple sites on the same nerve are stimulated
or recorded. Motor, sensory, mixed motor/sensory, or H-reflex tests are each counted per nerve tested.
Letter dated March 30, 2015 shows Utilization Review Determination & Authorization for EMG/NCV Bilateral Lower
Extremities, Begin Date: 3/26/2015, Expiration Date: 5/10/2015. Letter also states “
The treatment noted above has been determined to be medically necessary”
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Authorization dated March 30, 2015 is contract in nature. Therefore, reimbursement for 95912 is warranted.
95913 and 95937 EOR’s indicate service 95913
down-coded to reflect “contract
rate.”
Contractual Agreement not submitted for review; EOR indicates PPO reduction of 85% OMFS.
Referral with request for EMG/NCV and Neurodiagnostic Testing for left upper extremities identified in review.
AMA CPT Code Description: 95913 Nerve Conduction studies; 13 or more

Documentation includes dictated evaluation report and computerized results of studies. Data and Interpreted Report indicate
service 95913, specifically 13 nerve studies performed on the left upper extremities.
CPT 95937 denied by the Claims Administrator due to “service is for a condition which is not related to the covered work
related injury.”
95937 AMA CPT Assist: 95937 CPT Code 95937 -Neuromuscular Junction Studies
Repetitive stimulation studies are used to identify and to differentiate disorders of the NMJ. This test consists of recording
muscle responses to a series of nerve stimulus (at variable rates), both before, and at various intervals after, exercise or
transmission of high-frequency stimuli.
These codes may be used in association with motor and sensory NCSs of the same nerves and are reimbursed separately.
When this study is performed, the physician's report should note characteristics of the test, including the rate of repetition of
stimulations, and any significant incremental or decremental response.
95937 Report can be found on page 4 of the submitted documentation.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for CPT 95913 and 95937.
Review “This service appears to be
unrelated to the patient’s diagnosis”
Provider is dissatisfied with denial of code 95937, Neuromuscular junction testing (repetitive stimulation, paired stimuli), each
nerve, any 1 method
Claims Administrator denied code indicating on the Explanation of Review “This service appears to be unrelated to the patient’s
diagnosis”
Referral from AME to Provider requesting EMG bilateral upper extremities R/O radiculopathy was identified for this review.
Computerized test results along with narrative interpretation of findings was submitted for review.
Based on information reviewed, reimbursement of 95937 is warranted.

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.
Provider seeking remuneration of code 95937 performed on 8/6/2015.
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. The nerve studied was the ABD Hallucis.” Provider did not
bill 95937 with modifier -50, bilateral.
Referral to QME requesting EMG/NCV and Neurodiagnostic Testing for bilateral lower extremities identified in review.
95937: Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.
AMA CPT Assistant: To demonstrate and characterize abnormal neuromuscular transmission, repetitive nerve stimulation
studies should be performed in up to two nerves and SFEMG in up to two muscles.
Provide r documented NCV testing and computerized findings in submitted report for date of service 8/6/2015.
Report documents computerized results of two units, one right and one left abductor Hallucis.
Reimbursement is warranted for 95937x 2units
96101 The Claims Administrator’s based
reimbursement on the following
rational:“ applicable fee schedule.”
ISSUE IN DISPUTE: Provider seeking full remuneration for 96101 services performed on 04/27/2015.
The Claims Administrator’s based reimbursement on the following rational:“ applicable fee schedule.”
Med-Legal services not in dispute; units of 96100 is disputed by the Claims Administrator; EOR reflects 5 of 7 submitted units
reimbursed.
§ 9794 Reimbursement of Medical-Legal Expenses.
(a) The cost of comprehensive, follow-up and supplemental medical-legal evaluation reports, diagnostic tests, and medical-legal

testimony, regardless of whether incurred on behalf of the employee or claims administrator, shall be billed and reimbursed as
follows:
(1) X-rays, laboratory services and other diagnostic tests shall be billed and reimbursed in accordance with the official medical
fee schedule adopted pursuant to Labor Code Section 5307.1. In no event shall the claims administrator be liable for the cost of
any diagnostic test provided in connection with a comprehensive medical-legal evaluation report unless the subjective complaints
and physical findings that
warrant the necessity for the test are included in the medical-legal evaluation report. Additionally, the claims administrator shall
not be liable for the cost of diagnostic tests, absent prior authorization by the claims administrator, if adequate medical
information is already in the medical record provided to the physician.
Psychological Report, Page 17, the following time factors associated with each psychological exam are noted:
MMPI-2 = 1.5 hours
MCMI-III = 1.5 hours
Sentence Completion Test = .5 hours
Whaler Physical Symptom Inventory = .5 hours
Beck Depression Scale = 1 hr
Beck Anxiety Scale = 1 hr
Work Function Impairment Form Questionnaire = 1 hr
Total Hours = 7
Based on the aforementioned documentation and guidelines, additional reimbursement
is indicated for 96101 pursuant to § 9794.
96101-
59, 96102, 90899, and

WC
007 96101 -59, 96102,
90899, and WC007
ISSUE IN DISPUTE
Provider seeking additional remuneration for 96101-59, 96102, 90899, and WC 007 ervices performed
10/13/2015.
The Claims Administrator denied codes with rationale “
Communication from Legal Parties authorizing Med-Legal services reviewed.
Code Description CPT 96101 Psychological; testing (includes psychodiagnostic assessment of emotionality, intellectual
abilities, personality and psychopathology, e.g., mmpi, rorschach, wais), per hour of the psychologist's or physician's time, both
face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.
96102: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by
technician, per hour of technician time, face-to-face.
Page 1 of the Provider’s Psychological Consultation Report documents “6 hours of Psychological test completion and
interpretation by a psychologist ; 96102 -59 for 1 additional hour of test assessment and scoring by a psychologist”
Per Correct Coding Policies for NCCI Policy Manual for Medicare Services, 1/1/2015 chapter 1 Mutually Exclusive
Procedures-Many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually
exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter.
CPT codes 96101 and 96102 are mutually exclusive of each other and cannot be reimbursed separately. Therefore,
reimbursement of 96102 is not warranted.
A pair code does exist between reimbursed code 99205 and 96101, however, modifier indicator column shows ‘1’ stating that if
an approved modifier is appended to the column ‘2’ code, and documentation supports billed code, then the edit may be
overridden.
Column ‘2’code 96101 has approved modifier -59 appended and documentation does support billed code. Reimbursement of
96101 is warranted.
Request for Authorization shows “Service/Good Requested: Psych Consultation, Extended Time, Testing Interpretation by
Tech., Psychological Testing and Report; CPT/HCPCS code: 99205, 99354, 96102, 96101 and WC007” and is signed and dated
10/9/15 by Claims Administrator
showing “Approved”
Based on aforementioned guidelines and documentation, additional reimbursement of 96101 and WC007 is warranted

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”
Provider is dissatisfied with denial of codes WC007-30 and 96101-59, Psychological testing (includes psychodiagnostic
assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of
the psychologist's or physician's time, both face-to-face time administering
tests to the patient and time interpreting these test results and preparing the report.
Claims Administrator denied WC007-30 with rationale “This report does not fall under the guidelines for a separately
reimbursable report found in the General Instructions Section of the Physician’s Fee Schedule”
Modifier -30 states: Consultation reports requested by the Qualified Medical Evaluator (“QME”) or Agreed Medical Evaluator
(“AME”) in the context of a medical-legal evaluation. Use WC007, modifier -30.
A request for Provider to submit a report was not identified in this review. Therefore, reimbursement of WC007 is not
warranted.
Claims Administrator denied 96101 with rationale “Per CCI edits, the value of this procedure is included in the value of the
comprehensive procedure”
Provider billed code 96101 with modifier -59 which is an approved modifier to append to the column ‘2’code.
Psychological Testing Report submitted documents 9.5 hours of time involved for application, scoring and interpretation.
Based on information reviewed and guidelines, reimbursement of 96101 is warranted
96101 x 7 ANALYSIS AND FINDING
ISSUE IN DISPUTE: Provider seeking full remuneration for Psychological Testing 96101 Per Hour s
services performed on 08/29/2014 as part of a Medical Legal Evaluation.
The Claims Administrator denied the service indicating: “Workman’s Compensation Fee Schedule Adjustment. The Amount
adjusted is due to bundling or unbundling of service.”
Unless otherwise agreed upon by Claims Administrator and Provider, National Correct Coding Initiative do not apply to
Medical Legal claims.
Contractual Agreement regarding capitation relating to 96101 service as part of a Medical Legal Exam
not indicated on 07/25/2014 correspondence to Provider, the “Agreed Medical Evaluator in the field of psychiatry.”
07/25/14 Communication to AME from Legal Parties directs the AME to “examine the applicant, perform any non-invasive
testing that you deem reasonable and necessary...”
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.
CPT 96101: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, mmpi, rorschach, wais), per hour of the psychologist's or physician's time, both face-to-face time
administering tests to the patient and time interpreting these test results and preparing the report
EOR Reflects ML104 Evaluation accepted and reimbursed by Claims Administrator.
EOR Reflects 96101 Psychological Testing reimbursed for 5 Units.
AME Evaluation, page 11, under “Psychological Testing,” Paragraph three (3), the AME documents a total of 7 total hours
spent on various psychological testing. The table below describes the pertinent claim line information
96101-59 and 99354 The Claims Administrator denied
charges as “included” in the value
of other services performed on the
same day.
96101-59 Psychological Testing and 99354 Face-to-Face Per Hour Prolonged Services performed on 11/30/2015.
Authorization dated “September 20, 2015,” signed by the Claims Administrator indicates a “One Time Consultation” to the
Provider in order to address the following Applicant issues:
1)Determine if Events relating to injury is “considered sudden and extraordinary.”
2)If “complaints of stress meet 51% threshold...”
Opportunity to Dispute Eligibility communicated with Claims Administrator on 02/01/2015; Response received
02/15/2016 indicating initial claim only recently received and is currently in process for review. However, submitted
documentation indicates the following processed dates for this claim:
Initial EOR Processed 11/25/2015 DCN # 5120151112078222
Final EOR Processed 01/12/2016, DCN # 8120161223082141
EOR’s indicate 95% Contract Rate
Psychological Report reviewed for 99354. Page 1, the Provider indicates Face-to-Face interview required “2 hours (4-6
PM).”EOR indicates 99205 60 min New Patient Evaluation and Management services. EOR indicates Provider reimbursed for
99204. Based on reported time and nature of evaluation, 99205 time component dictates the level of service.
96101-59 Psychological Testing Per Hour is a paired code to 99205. However, the reported Modifier and Documentation
support standalone services.
Page 1 of Psychological report, the Provider indicates “Administration, scoring and interpretation of psychological testing
required 4 hours.”
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 96105-59 and 99354
.

96101-59, 96102,
90899, and WC007
The Claims Administrator denied
codes with rationale
“
Communication from Legal Parties authorizing Med-Legal services reviewed.
Code Description CPT 96101 Psychological; testing (includes psychodiagnostic
assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., mmpi, rorschach, wais), per hour of the
psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results
and preparing the report.
96102: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by
technician, per hour of technician time, face-to-face.
Page 1 of the Provider’s Psychological Consultation Report documents “6 hours of Psychological test completion and
interpretation by a psychologist; 96102-59 for 1 additional hour of test assessment and scoring by a psychologist”
Per Correct Coding Policies for NCCI Policy Manual for Medicare Services, 1/1/2015 chapter 1 Mutually Exclusive Procedures-
Many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually exclusive
procedures cannot reasonably be performed at the same anatomic site or same patient encounter.
CPT codes 96101 and 96102 are mutually exclusive of each other and cannot be reimbursed separately. Therefore,
reimbursement of 96102 is not warranted.
A pair code does exist between reimbursed code 99205 and 96101, however, modifier indicator column shows ‘1’stating that if
an approved modifier is appended to the column ‘2’ code, and documentation supports billed code, then the edit may be
overridden.
Column ‘2’ code 96101 has approved modifier -59 appended and documentation does support billed code. Reimbursement of
96101 is warranted.
Request for Authorization shows “Service/Good Requested: Psych Consultation, Extended Time, Testing Interpretation by
Tech., Psychological Testing and Report; CPT/HCPCS code: 99205, 99354, 96102, 96101 and WC007” and is signed and dated
10/9/15 by Claims Administrator showing “Approved”
Based on aforementioned guidelines and documentation, additional reimbursement of 96101 and WC007 is warranted

96118 and 90791 The Claims Administrator’s
reimbursement for services was
based on an indicated “contract.”
ISSUE IN DISPUTE: Provider seeking full OMFS remuneration for 96118 Neuropsych
Testing and 90791 Psych Diagnostic Evaluation services performed 01/08/2015.
The Claims Administrator’s reimbursement for services was based on an indicated “contract.”
Authorization 01/14/2015 with stamped signature by Claims Administrator agreed to the following for 96118 and 90791
services: “Agree to pay based on CA fee Schedule,” hand written on authorization.
EOR’s reflect charges based on “PPO” reduction.
Initial Neuropsychological Evaluation reviewed, time is documented for codes in dispute. Pursuant to LC § 5307.11: A health
care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant
to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety
Code, and a
contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee
schedule for that health care provider or healthfacility licensed pursuant to Section 1250 of the Health and Safety Code shall not
apply to the contracted reimbursement rates.
Based on the aforementioned documentation and guidelines, additional remuneration is
warranted for 96118 and 90791.

Review “CCI: Standards of
Medical/Surgical Practice” and
“included within the value of
another service performed on the
same day”
Provider is dissatisfied with denial of code 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”
RFA dated 12/09/2014 documents CPT codes 99205, 99354, 99358, 96118 and WC005.
As a pair code does exist between codes 96118 and 99205 , Provider appended modifier -25 to 96118. Modifier -25: Significant,
separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service.
Per NCCI Edits, status indicator column shows ‘1’ which states that if an approved modifier is appended to the column ‘2’ code,
and documentation is submitted to support the billed code, then the edit may be overridden.
Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:Anatomic modifiers:
E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI; Global surgery modifiers: 24, 25, 57, 58, 78, 79; Other modifiers:
27, 59, 91, XE, XS, XP, XU
Provider appended modifier -25 which is one of the approved modifiers.
CPT 96118 -Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and
Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the
patient and time interpreting these test results and preparing the report
Report dated June 12, 2015 titled Comprehensive Initial Neuropsychological Evaluation Report , documents
“evaluation consisted of 2 hours of face-to-face interview with the patient and 13 hours of testing, scoring and interpretation. ”
Pages 6 & 7 of Provider’s report documents tests administered.
Documentation submitted supports billed code 96118.
Based on information reviewed, reimbursement of 96118 is warranted.
EOR received reflects a 10% PPO discount is to be applied to reimbursement.
The table below describes the pertinent claim line inform

97110-GP The Claims Administrator’s
reimbursement rational indicates:
“Contract Rate.”
9789.15.4 Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for
Specified Procedure/Modality Services (1) The Medicare Multiple Procedure Payment Reduction (“MPPR”) for “Always
Therapy” Codes shall be applied when more than one of the following codes is billed on the same day: codes on the Medicare
“Always Therapy” list, acupuncture codes, chiropractic manipulation codes. (2) 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
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
Per NCCI Edits mentioned, generally codes 97150 and 97113 are not billed together. However, Modifier Indicator column shows
‘1’ which states if the correct code has an approved NCCI modifier appended, and documentation is submitted to support code
used, then the edit may be overridden.
Modifier -59 is an approved modifier and may be used to support billed code 97113. We billed CPT 97113 with modifier -59
on the CMS 1500 form for both dates of service.
97113 -Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises.
 Documentation received included Daily Note/Billing Sheet which documents services Performed 97113 as well as
service 97150Documented start and stop time for each procedure submitted
97140 Service denied by Claims
Administrator as “Mutually
exclusive procedures.”
Provider seeking remuneration for 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic
drainage, manual traction), 1 or more regions, each 15 minutes performed on dates of service 07/20/2015, 07/22/2015 &
07/29/2015 .
Service denied by Claims Administrator as “Mutually exclusive procedures.”
Provider billed code along with 98940 on a CMS 1500 form for all three dates of service.
As pair code does exist between 97140 and 98940, modifier indicator column shows ‘1’ which states that if an approved
modifier is appended to the column 2 code, and documentation supports billed code, then the edit may be overridden.
Provider appended approved modifier ‘XS’-Separate Structure, A service that is distinct because it was performed on a separate
organ/structure , to column 2 code 97140.
Progress notes document service 97140 as myofascial release to the forearm and CMT to T1.
Documentation supports services performed.
Opportunity to Dispute sent to Claims Administrator on 11/16/2015; response not yet received.
Based on the aforementioned documentation, reimbursement is indicated for 97140x 3.
EOR received reflects a 10% PPO discount to be applied to reimbursement

97530 x 4 Units The Claims Administrator denied
the services indicating: “Per CCI
Edits, the value of this procedure is
included in the value of the
mutually exclusive procedure.”
Provider seeking remuneration for 97530-59 x 4 Units Physical Medicine services performed on 02/26/2014 –03/05/2014.
The Claims Administrator denied the services indicating: “Per CCI Edits, the value of this procedure is included in the value of
the mutually exclusive procedure.”
-59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same
patient encounter.”
Documentation of Patient visit includes Exercise Log noting duration of each exercise.
Documentation regarding start and end times for 97530 Therapeutic Exercise and 97140 Manual Exercise, were not noted.
Times entries for each exercise did not clarify whether the
sessions were performed separately, simultaneously, or sequentially Provider seeking remuneration for
97530-59 x 4 Units Physical Medicine services performed on 02/26/2014 –03/05/2014.
The Claims Administrator denied the services indicating: “Per CCI Edits, the value of this procedure is included in the value of
the mutually exclusive procedure.”
-59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same
patient encounter.”
Documentation of Patient visit includes Exercise Log noting duration of each exercise.
Documentation regarding start and end times for 97530 Therapeutic Exercise and 97140 Manual Exercise, were not noted.
Times entries for each exercise did not clarify whether the sessions were performed separately, simultaneously, or sequentially

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.”
Provider is dissatisfied with denial of CPT 97530-59. Provider billed codes 97140, G0283 and 97530
-59.
97530 is a time based code 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 mutually exclusive procedure.”
NCCI edits state that generally 97140 and 97530 are not reported together. However, Modifier Indicator column shows ‘1’
which states if the appropriate modifier is appended to the correct code, and proper documentation is supporting the code, then
the NCCI edit may be overridden.
Pursuant to Labor Code section 5307.27, MTUS shall address, at a minimum, “the frequency, duration, intensity, and
appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.”
On review of documentation submitted which included the testing that was done on date of service
05/02/2014 . Provider documents time for CPT 97530 and 97140 with description of procedures performed. Therefore,
reimbursement of 97530-59 is recommended.
Claims Administrator shows a PPO discount of 15% was applied to reimbursement which was not disputed. Therefore, 15%
discount shall be applied.

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.”
Provider is dissatisfied with denial of CPT 97530-59 and 97750-59. Provider billed codes 97140, G0283, 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.”
NCCI edits state that generally 97140, 97530 and 97750 are not reported together. However, Modifier Indicator column shows
‘1’ which states if the appropriate modifier is appended to the correct code, and proper documentation is supporting the code,
then the NCCI edit may be overridden.
Pursuant to Labor Code section 5307.27, MTUS shall address, at a minimum, “the frequency, duration, intensity, and
appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.”
On review of documentation submitted which included the testing that was done on date of service 5/07
/2014, no start and stop times are recorded as needed for code 97750. Provider documents time for CPT 97530 but not 97750.
Therefore, reimbursement of 97750 is not recommended.
Claims Administrator shows a PPO discount of 15% was applied to reimbursement which was not disputed. Therefore, 15%
discount shall be applied.

reimbursement as “not reimbursable
under Medicare Hospital Outpatient
Fee Schedule.”
Provider seeking $195.00 in remuneration for 97545 Work Conditioning services performed on 04/15/2015.
The Claims Administrator denied reimbursement as “not reimbursable under Medicare Hospital Outpatient Fee Schedule.”
OMFS 97545 Code Definition: Work Conditioning (97545) is a work related, intensive, goal oriented treatment program
specifically designed to restore an individual's systemic, neuromusculoskeletal (strength, endurance, movement, flexibility, and
motor control) and cardiopulmonary functions. The objective of the Work Conditioning program is to restore the client's
physical capacity and function so the injured worker can return to work. Prior authorization is required.
CPT 97545 is a reimbursable service under the OMFS pursuant to CCR § 9789.32, “Other Services,” and is a “By Report ”
procedure code.
Authorization dated 02/24/2015, signed by RN Case Manager reflects “6 sessions,” as “approved.”
97545 reflected on the OMFS has a Relative Value of “0” and there is no comparable service code.
OMFS: General Information and Instructions, Physical Medicine: In some instances the values of BR procedures may be
determined using the value assigned to a comparable procedure. The comparable procedure should reflect the same amount of
time, complexity. expertise etc., as required for the procedure performed.
A “comparable” service does not exist for this comprehensive program and is treated as a ‘By Report’ code where a Contractual

Agreement or the Provider’s Usual and Customary charge dictates reimbursement.
Opportunity to Dispute Edibility sent to Claims Administrator on 09/30/2015; response not yet received.
PPO Contractual Agreement not available for IBR.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97545.
reimbursement as “not reimbursable
under Medicare Hospital Outpatient
Fee Schedule.”
Provider seeking $195.00 per unit remuneration for 97545 Work Conditioning services performed on 03/16/2015, 03/27/0015,
04/01/2015 & 04/08/2015.
The Claims Administrator denied reimbursement as “not reimbursable under Medicare Hospital Outpatient Fee Schedule.”
OMFS 97545 Code Definition: Work Conditioning (97545) is a work related, intensive, goal oriented treatment program
specifically designed to restore an individual's systemic, neuromusculoskeletal (strength, endurance,
movement, flexibility , and motor control) and cardiopulmonary functions. The objective of the Work Conditioning program is to
restore the client's physical capacity and function so the injured worker can return to work. Prior
authorization is required.
CPT 97545 is a reimbursable service under the OMFS pursuant to CCR § 9789.32, “Other Services,” and is a “By Report”
procedure code.
Authorization dated 02/24/2015, signed by RN Case Manager reflects “6 sessions,” as “approved.”
97545 reflected on the OMFS has a Relative Value of “0” and there is no comparable service code.
OMFS: General Information and Instructions, Physical Medicine: In some instances the values of BR procedures may be
determined using the value assigned to a comparable procedure. The comparable procedure should reflect the same amount of
time, complexity. expertise etc., as required for the procedure performed.
A “comparable” service does not exist for this comprehensive program and is treated as a ‘By Report ‘code where aContractual
Agreement or the Provider’s Usual and Customary charge dictates reimbursement.
Opportunity to Dispute Edibility sent to Claims Administrator on 09/30/2015; response not yet received.
PPO Contractual Agreement not available for IBR.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97545

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