Physician Visits and Physician Mobile Office Visits
physician visits (services) require prior authorization after the first visit;
however, the first and following visits must meet the Miller Criteria.
physician visits may be appropriate and should be approved only when the
injured worker is homebound and is unable to access outpatient facilities
because of sensory impairment, immobility or transportation problems due to
physical limitations. Examples might include injured workers with catastrophic
conditions or those requiring end of life care. Lack of transportation does not
constitute a medical reason for approving in-home physician visits.
approval shall be granted by the MCO according to the plan of care and health
care needs for the specific injured worker. Reimbursement to physicians will be
made using Current Procedural Terminology (CPT) codes for Home Visits and the
level of code must reflect current coding documentation standards for the CPT
level of service. Services rendered must only be those services indicated by the
circumstances that are medically necessary.
van or trailer physician visits or services, when the injured worker walks to
the van or trailer, will be reimbursed as a normal office visit according to
CPT levels of service and will not be eligible for billing as a home
visit. Mobile offices must bill using the appropriate office or other
outpatient services CPT evaluation and management code, with place of service
15 (mobile unit) and will be reimbursed at BWC’s Non- Facility Fee.
physician chooses to make a home visit to an injured worker who does not meet
the criteria for a home visit or when determined by the MCO/BWC not to be
medically necessary, the physician may not bill the services as a home
visit. If the services are considered medically appropriate and necessary if
delivered in a customary office setting, the physician must bill using the
appropriate office or other outpatient services CPT evaluation and management
code, with place of service 12 (home) and will be reimbursed at BWC’s Facility