Jamie Posted Tue 20th of August, 2019 16:41:34 PM
We are contracted with a patient's Insurance company, and during a phone call they stated that they will cover work-related examinations, to include FAA exams when billed under CPT® 99455 and completed by a FAA certified examiner. An FAA exam is required periodically for pilots to evaluate their ability to fly according to FAA's guidelines. According to CPT®, code 99455, "is performed to establish baseline information prior to ... disability insurance certificates being issued". The 2018 Supercoder Article in the Part B Coding Coach: Prepare for School, Sports, and Occupational Exams with These Codes, Published on Thu Mar 22, 2018 states "Similarly, for work-related physicals, you must not use 99455 (Work related or medical disability examination by the treating physician ...) or 99456 (... by other than the treating physician...)." as they are related to Disability exams. The CPT® codes description does state "Work related OR medical disability examination". An FAA exams and a DOT exams are done to see if a pilot or driver has any significant impairment or disability that would prevent them from completing their duties safely. Is the "Or" in the description referencing that is can be work related OR disability related? Or is it stating that the its a work related disability OR a general medical disability? Should we match the characteristics of the exam with the bullet points required for the use of 99455 to decide if it is appropriate?
The struggle is, when there is conflicting coding information between CPT® guidelines and a contracted Insurer, whose rules do we follow?
Question 1: Is 99455 appropriate, if the bullets are met, for FAA and DOT exams?
Question 2: If it isn't, whose guideline do we follow, the contracted insurance or CPT®?
Thank you in advance for the support!
SuperCoder Answered Wed 21st of August, 2019 07:36:27 AM
Thank you for the query.
CPT code 99455 is for work related disability examination OR for medical disability examination. This code is specific to disability examiation. You should bill this code for disability examination performed to identify the work hampering occuring due to work related disability or medical condition related disability. For general physical examination, you should not bill this code.
If your documentation meets all the bullet points of the code, then you can bill this CPT code.
Jamie Posted Tue 17th of September, 2019 12:04:41 PM
What do we do when an Insurance company states that for FAA and DOT exams that 99455 is the code to use? do we code by ins guidelines or CPT?
SuperCoder Answered Wed 18th of September, 2019 03:41:09 AM
Generally coding should be done as per the coding guidelines and CPT guidelines set forth by federal bodies. If your insurance is suggesting you to bill CPT code 99455 for FAA and DOT exams, then you can bill CPT code 99455. Please ensure you get the policy document for CPT code 99455 from the payer. Provided documentation should clearly state the terms, conditions and policies related to CPT code. It should clearly state the terms/conditions, when we can bill this code. In case of any future denial, this document would be handy.
Hope provided information would be helpful.