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Allan Colledge
and
Greg Krohm

Abstract

The AMA Current Procedural Terminology (CPT) codebook lists specific codes that can be used for impairment ratings, and in some industrial cases insurance carriers require an impairment rating determination at medical stability for which a CPT code is needed. For billing purposes, an impairment rating performed by the treating physician usually is considered an extension of the treatment process (office visit, medical records review, diagnostic studies, current physical findings, and a written report). A table in this issue of The Guides Newsletter shows current nonspecific CPT procedure codes; if the report does not conform to the established criteria as outlined in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), the evaluating physician may not be entitled to reimbursement. A work-related or medical disability examination involves taking a medical history commensurate with the patient's condition, examination, diagnosis, assessment of capabilities and stability, calculation of impairment, development of a treatment plan, and completion of documentation or certificates and report. Treating physicians who perform the examination can bill this work using CPT code 9455; CPT code 99456 applies if a nontreating physician performed the work (the code is used for each 30-minute increment). AMA recommends tht payment for these codes be dependent on the complexity of the case, the time required in the evaluation and report writing, and the value of the examiner's time.

in AMA Guides® Newsletter
Alan Colledge
and
Greg Krohm

Abstract

The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) specifies that impairment evaluation may be conducted by a treating or nontreating physician. A treating physician who is knowledgeable about the use of the AMA Guides may be the appropriate professional to evaluate impairment, but in cases that involve pain, disability, and medicolegal (forensic) issues, a truly independent medical examiner typically is most appropriate. All specialties share the same elevated risk of iatrogenesis when treating and evaluating/forensic roles are mixed because mixing compromises the quality of care and threatens the viability of the therapeutic relationship. Further, all treating specialties share the same bias toward offering treatment for most complaints—rather than engaging in the type of cautious skepticism that is required for competent impairment evaluation and other forensic duties. Finally, no treating clinician, regardless of specialty, can offer allegiance to judicial and administrative decision-makers. Treating clinicians often find themselves in a position in which they would be cutting off a source of their own income if they were to offer opinions that the clinical presentation is not valid, work related, or injury related, nor is the patient in need of further treatment. Such a financial conflict of interest can be eliminated only by referral to independent examiners and restricting treating clinicians from becoming involved in such decisions.

in AMA Guides® Newsletter