OCCUPATIONAL HEALTH SERVICES PHYSICIAN REFERRAL FORM



Center of Occupational Health & Education Patient Name:

Provider Medical Conference Form Claim Number:

Date of Birth:

Team Conference/Telephone Calls/Online Communication

Date of conference/call/e-mail: Patient’s diagnosis:

Your name and title: New/additional diagnosis:

Attending provider name and title:

Nature of/Reason for Conference:

← Address return-to-work issues

← Clarification of treatment plan

← Objective findings not consistent with subjective complaints

← Worsening of condition or not responding to treatment

← Potential surgical need

← Other:

Brief Summary of Conference: Team Conference Telephone Call Patient Present: Yes No

Name and title of all participants:

Length of conference:

Summary of medical, vocational or return-to-work decisions:

Team Conference Only: Specify medical/surgical treatment plan: (goal oriented, time-limited & must return pt to appropriate level of function)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Recommendation/Actions to be taken:

← Further diagnostics indicated – (specify)

← Specialist examination (specify type of specialty)

← Surgical consultation (Specify type of surgeon needed)

← Referral for physical therapy/occupational therapy

← Referral for performance based physical capacity evaluation

← Referral for health services coordination or nurse consultant review

← Referral for vocational rehabilitation

← Other:

Provider Signature Date

Billing Codes: Reference: L&I Medical Aid Rules & Fee Schedule 2009 -MARFS and Current Procedural Terminology 2009 -CPT® 2009 codes.

Team conference: (pt not present) Telephone call: (pt not present) Online communication-e-mail/secure

message in CAC: (pt not present)

PA/ARNP MD/DO/DC PA/ARNP MD/DO/DC PA/ARNP MD/DO/DC

( 99368 ( 99367 (98966 Brief (5-10 min) ( 99441 ( 99969 ( 99444

(Other _________ (98967 Intermediate (11-20 min) ( 99442

(Appropriate code for today’s visit) (98968 Complex (21-30 min) ( 99443

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Fax to claim file: 360 902-4292 360 902-4565 360 902-4566 360 902-4567

(choose any telephone number) 360 902-5230 360 902-6100 360 902-6252 360 902-6460

L&I Requirements for Team Conferences, Telephone Calls & Online Communications

CASE MANAGEMENT SERVICES - Team Conferences

Team conferences may be payable when the attending provider, consultant or psychologist meets with one or more of the following:

• An interdisciplinary team of health professionals

• L&I staff

• Vocational rehabilitation counselors

• Nurse case managers

• L&I medical consultants

• Self-insurer representatives or employers

• Physical and occupational therapists and speech-language pathologists

Billing codes: Team conferences

Patient status Patient present – use appropriate level E&M code.

CPT® code (Physicians) Patient present – use appropriate level of E&M code; Patient not present – 99367.

CPT® code (Nonphysicians) Patient present – 99366; Patient not present – 99368.

Multiple units of 99366, 99367 and 99368 may be billed for conferences exceeding 30 minutes

Duration of face to face team conference: Units billed: Up to 30 minutes - 1 unit and up to 60 minutes - 2 units

Physical and Occupational Therapists

Physical and occupational therapists and speech-language pathologists may be paid for attendance at a team conference only when the conference is authorized in advance by the Medical Director/Associate Medical Director at L&I or the self-insured employer.

To be authorized all of the following criteria must be met:

0. There is a moderate to high probability of severe, prolonged functional impairment. This may be addressed with the development of a multidisciplinary approach to the plan of care; and

0. The need for a conference exceeds the expected routine correspondence/communication among healthcare/vocational providers; and

0. The worker is not participating in a program in which payment for conference is already included in the program payment (For example, head injury program, pain clinic, work hardening); and

0. 3 or more disciplines/specialties need to participate, including PT, OT or Speech.

To be paid for the conference the therapists must:

0. Bill using CPT® code 99366 if the patient is present or 99368 if the patient is not present.

0. Bill on a CMS-1500 form

0. Submit a separate report of the conference; joint reports are not allowed. The conference report must include:

• Evaluation of the effectiveness of the previous therapy plan; and

• New goal-oriented, time-limited treatment plan or

• Objective measures of function that address the return-to-work process.

• Duration of the conference

NOTE: Providers in a hospital setting may only be paid if the services are billed on a CMS-1500 with an individual provider account number.

Billing codes and duration: Telephone calls

CPT® codes: (Physicians) 5-10 minutes – 99441; 11-20 minutes 99442; 21-30 minutes 99443.

CPT® codes: (Nonphysicians) 5-10 minutes – 98966; 11-20 minutes 98967; 21-30 minutes 98968.

Telephone calls are payable to the attending provider, consultant psychologist or other provider, only when they personally

participate in the call. These services are payable when discussing or coordinating care or treatment with:

• the worker, L&I staff, vocational rehabilitation consultants, nurse case managers, health services coordinators (COHE), L&I medical

consultants, other physicians, other providers, (e.g. consultants), self-insurer representatives or employers.

NOTE: L&I does not adhere to the CPT® limits for telephone calls

• Telephone calls are payable regardless of when the previous or next office visit occurs.

• ARNPs, PAs, psychologists, PTs and OTs must bill using non-physician codes.

• Telephone calls for authorization, resolution of billing issues or ordering prescriptions are not payable.

Billing codes and duration: Online Communications (e-mail or secure messages)

CPT® codes: (Physicians) 99444; CPT® codes: (Nonphysicians) 98969

Electronic communications: are payable when discussing or coordinating care, treatment or return-to-work activities with L&I staff, vocational rehabilitation counselors, case managers, L&I medical consultants, self-insured representatives or employers.

• All electronic online communications (e-mail) to coordinate care must be made personally by the attending provider.

• Electronic online communications (e-mail) with the worker are payable only when personally made by the attending provider, consultant, psychologist or physical or occupational therapist who has an existing relationship with the worker.

• Online communications must be conducted over a secure network… Please see page 38 of L&I’s Medical Aid Rules and Fee Schedule (MARFS) for specific instructions.

Documentation Requirements: Documentation for electronic communications must include: date, participants & titles, the nature of the communication and all medical, vocational or return to work decisions made.

7-1-09 CPT® codes and descriptions only are 2008 American Medical Association. Pages 35-36. Page 38.

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