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Workers’ comp codes status B

APCs Weekly Monitor, September 3, 2004

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QUESTION: One of my physicians brought me an article regarding CPT codes for workers' compensation, which suggested we should be using codes 99455 and 99456. These codes also have a higher fee than a regular office visit. Should we change our chargemaster to reflect this instruction?

ANSWER: CPT codes 99455 and 99456, listed below, are identified with status indicator B, "codes that are not recognized by OPPS when submitted on an outpatient hospital part B bill type (12X, 13X, and 14X)."

• 99455-work-related or medical disability examination by the treating physician that includes: completion of a medical history commensurate with the patient's condition; performance of an examination commensurate with the patient's condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report
• 99456-work-related or medical disability examination by other than the treating physician that includes: completion of a medical history commensurate with the patient's condition; performance of an examination commensurate with the patient's condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report

Both appear to be carrier-specific CPT codes reserved for physician use only. Use of both codes is generally at the discretion of a workers' compensation carrier, such as for an independent medical exam (IME) to determine a disability. The heading in the 2004 CPT book states that these codes are special E/M services, not your typical E/M services, so hospitals should work closely with carriers to determine the appropriate CPT codes to report. For more information, see the 8/16/04 Federal Register.

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