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Chapter 12: Impairment Rating Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2012

Complete Chapter for printing

 

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

Payment policy:
Impairment ratings

More info:
Related topics



 

Definitions

Body areas:

For rating impairment, the following body areas are recognized:

  • Head, including the face,
  • Neck,
  • Chest, including breasts and axilla,
  • Genitalia, groin, buttock,
  • Back,
  • Abdomen, and
  • Each extremity.

Note: Each extremity is counted once per extremity examined, when determining limited, standard, or complex codes.  For example, in a case of bilateral carpal tunnel syndrome, if both right and left extremities are examined, 2 body areas would be counted.

Organ systems:

For rating impairment, the following organ systems are recognized:

  • Eyes,
  • Ears, nose, mouth, and throat,
  • Cardiovascular,
  • Gastrointestinal,
  • Respiratory,
  • Genitourinary,
  • Musculoskeletal,
  • Skin,
  • Neurologic,
  • Psychiatric, and
  • Hematologic/ lymphatic/ immunologic.

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Payment policy: Impairment ratings

Prior authorization

Prior authorization is only required when:

  • A psychiatric impairment rating is needed, or
  • An IME is scheduled.

Local billing code 1198M must be requested and authorized by the claim manager.

When and how to perform an impairment rating

When to rate impairment

When the worker has reached maximum medical improvement (MMI) or when requested by the insurer.  Impairment rating should occur during the closing exam.

Rate impairment only for medical conditions accepted under the claim.

Body areas and organ systems

The definitions of body areas and organ systems from Current Procedural Terminology (CPT®) book must be used to distinguish between limited, standard, and complex impairment rating.

Note: See definitions of body areas and organ systems in “Definitions” at the beginning of this chapter.

How to rate impairment

Use the appropriate rating system.

Link: For an overview of systems for rating impairment, see the Medical Examiners’ Handbook (F252-001-000).

Include the objective findings to support the impairment rating.  The objective medical information will also be needed if a worker requests the claim be reopened.

Impairment rating reports must include all of the following elements:

  • MMI: Statement that the patient has reached maximum medical improvement (MMI) and that no further curative or rehabilitative treatment is recommended, and
  • Physical exam: Pertinent details of the physical examination performed (both positive and negative findings), and
  • Diagnostic tests: Results of any pertinent diagnostic tests performed (both positive and negative findings). Include copies of any pertinent tests or studies ordered as part of the exam, and
  • Rating: An impairment rating consistent with the findings and a statement of the system on which the rating was based.  For example:
    • The AMA Guidelines to the Evaluation of Permanent Impairment and the edition used, or
    • The Washington state category rating system, and

Links:  Refer to WAC 296-20-19000 through WAC 296-20-19030 and WAC 296-20-200 through WAC 296-20-690 , and for amputations refer to RCW 51.32.080 .

Rationale: The rationale for the rating, supported by specific references to the clinical findings, especially objective findings and supporting documentation including the specific rating system, tables, figures and page numbers on which the rating was based.

Note: If there isn’t an impairment, document that in your report.

Who must perform these services to qualify for payment

Attending providers who are permitted to rate their own patients don’t need an IME provider account number and may use their existing provider account number.

Qualified attending providers (AP) may rate impairment of their own patients.

Providers may only give ratings for areas of the body or conditions within their scopes of practice.

If the AP is unable or unwilling to perform the rating examination, the AP can ask a consultant to perform the rating examination.

Psychologists may not be an attending provider (except for Crime Victim’s claims) and may not rate impairment for injured workers or victims of crime.

To determine if you are qualified to provide this service, see table below:

If your provider type that you’re currently licensed in is… Then are you able to rate impairment as AP or consultant?
Medicine and surgery Yes
Osteopathic medicine and surgery Yes
Podiatric medicine and surgery Yes
Dentistry Yes
Chiropractic Yes, if L&I approved IME examiner
Naturopathy No
Optometry No
Physicians’ Assistant No
Advanced Registered Nurse Practitioners (ARNP), including Psychiatric ARNPs No

Links: To see how these qualifications are set in state law, see WAC 296-20-2010 .

For more details on the topic of impairment ratings, refer to the Medical Examiners’ Handbook (F252-001-000 ), available online at www.Lni.wa.gov/IPUB/252-001-000.pdf , and to the Attending Doctor’s Handbook (F252-004-000 ), available online at www.Lni.wa.gov/IPUB/252-004-000.pdf .

Services that can be billed

The impairment rating exam should be sufficient to achieve the purpose and reason the exam was requested.

Choose the local billing code based on the number of body areas or organ systems that need to be examined to fully evaluate the accepted condition(s) or the condition(s) contended as work related (see fee schedule, below).

Be sure the report documents the relationship of the areas examined to the accepted or contended conditions.

Impairment rating fee schedule, effective July 1, 2012:

Note: See definitions of body areas and organ systems in “Definitions” at the beginning of this chapter.


Local billing code
Description Maximum fee
1190M Impairment rating by attending physician, limited, 1 body area or organ system.
Use this code if there is only 1 body area or organ system that needs to be examined for sufficient evaluation of the accepted condition(s).  Included in this code are the following requirements:Familiarity with the history of the industrial injury or condition.
Physical exam is directed only toward the affected body area or organ system.
Diagnostic tests needed are ordered and interpreted.
Impairment rating is performed as requested.
Impairment rating report must contain the required elements noted in the Medical Examiners’ Handbook .
Office visits are considered a bundled service and are included in the impairment rating fee.  Definitions of organ systems and body areas can be found in the CPT® manual.
$443.02
1191M Impairment rating by attending physician, standard, 2-3 body areas or organ systems.
Use this code if there are 2-3 body areas or organ systems that need to be examined for sufficient evaluation of the accepted condition(s).  Included in this code are the following requirements:
Familiarity with the history of the industrial injury or condition.
Physical exam is directed only toward the affected body area or organ system.
Diagnostic tests needed are ordered and interpreted.
Impairment rating is performed as requested.
Impairment rating report must contain the required elements noted in the Medical Examiners’ Handbook .
Office visits are considered a bundled service and are included in the impairment rating fee.  Definitions of organ systems and body areas can be found in the CPT® manual.
$497.51

1192M
Impairment rating by attending physician, complex, 4 or more body areas, or organ systems.
Use this code if there are 4 or more body areas or organ systems that need to be examined for sufficient evaluation of the accepted condition(s).  Included in this code are the following requirements:
Familiarity with the history of the industrial injury or condition.
Physical exam is directed only toward the affected body area or organ system.
Diagnostic tests needed are ordered and interpreted.
Impairment rating is performed as requested.
Impairment rating report must contain the required elements noted in the Medical Examiners’ Handbook .
Office visits are considered a bundled service and are included in the impairment rating fee. Definitions of organ systems and body areas can be found in the CPT® manual.
$621.87
1194M Impairment rating by consultant, standard, 1-3 body areas or organ systems.
Use this code if there are 1-3 body areas or organ systems that need to be examined for sufficient evaluation of the accepted condition(s).  Included in this code are the following requirements:
Records are reviewed.
Physical exam is directed only toward the affected areas or organ systems of the body.
Diagnostic tests needed are ordered and interpreted.
Impairment rating is performed as requested.
Impairment rating report must contain the required elements noted in the Medical Examiners’ Handbook .
Office visits are considered a bundled service and are included in the impairment rating fee.  Definitions of organ systems and body areas can be found in the CPT® manual.
$497.51    
1195M Impairment rating by consultant, complex, 4 or more body areas or organ systems.
Use this code if there are 4 or more body areas or organ systems that need to be examined for sufficient evaluation of the accepted condition(s).  Included in this code are the following requirements:
Records are reviewed.
Physical exam is directed only toward the affected areas or organ systems of the body.
Diagnostic tests needed are ordered and interpreted.
Impairment rating is performed as requested.
Impairment rating report must contain the required elements noted in the Medical Examiners’ Handbook .
Office visits are considered a bundled service and are included in the impairment rating fee.  Definitions of organ systems and body areas can be found in the CPT® manual.
$621.87
1198M Impairment rating, addendum report.
Must be requested and authorized by the claim manager.
Addendum report for additional information which necessitates review of new records.
Payable to attending physician or consultant.
This code isn’t billable when the impairment rating report did not contain all the required elements.  (See the Medical Examiners’ Handbook for the required elements.)
$114.31  

Requirements for billing

APs use billing codes 1190M, 1191M, and 1192M.

Consultants use billing codes 1194M and 1195M.

Code 1198M must be requested and authorized by the claim manager.

Additional information: How to find out if an impairment rating is scheduled

Links: To see if an IME is scheduled, for a claim that is:


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If you’re looking for more information about… Then go here:
Administrative rules and
Washington state laws
for
impairment ratings

Washington Administrative Code (WAC) 296-20-19000:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-19000
WAC 296-20-19030:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-19030
WAC 296-20-200:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-200
WAC 296-20-2010:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-2010
WAC 296-20-690:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-690
Revised Code of Washington (RCW) 51.32.080:
http://app.leg.wa.gov/rcw/default.aspx?cite=51.32.080

Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 2:
Information for All Providers
Fee schedules for all healthcare
services (including impairment ratings)
L&I’s website:
http://feeschedules.Lni.wa.gov
How to perform an impairment rating L&I’s website:
Attending Doctor’s Handbook:
www.Lni.wa.gov/IPUB/252-004-000.pdf
Medical Examiner’s Handbook:
www.Lni.wa.gov/IPUB/252-001-000.pdf

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2011 American Medical Association

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