UPDATES: QME EN BANC, HICFA & ICD-10

QME physicians should not expect to see the same previous applicants if they have a subsequent claim of injury or illness. This decision will create opportunities for new QME physicians as they will have opportunities to be selected. However, if the disputed medical issue is related to treatment and utilization review disputes, the applicant will go to the Independent Medical Review (IMR) and may circumvent the entire QME selection process.

Ismael Navarro
v.
City of Montebello, administered by Corvel Corporation

April 2, 2014

Case No:ADJ6779197ADJ7472140ADJ7964720

79 Cal. Comp. Cases

The Appeals Board determined that for his two new claims of injury the applicant did not have to be evaluated by the panel qualified medical evaluator (panel QME) who previously evaluated him for his original claim of injury, holding that:

  1. The Labor Code does not require an employee to return to the same panel QME for an evaluation of a subsequent claim of injury; and
  2. The requirement in Rule 35.5(e) that an employee return to the same evaluator when a new injury or illness is claimed involving the same parties and the same type of body parts is inconsistent with the Labor Code, and therefore, this requirement is invalid.

NEW HICFA CMS 1500 DEADLINE APRIL 1, 2014

The new HICFA CMS 1500 form for submitting billing invoices is here. Most providers and billing companies are unaware of this change and may see additional delays denials in payments.

That old red HCFA we all know so well is getting a face lift to make room for expanding the number of diagnosis codes (up to 12 on the new form).
They also made space to differentiate between the role a provider plays for a patient– supervisor, referrer, ordering physician, etc.
They also created a way to differentiate between ICD-9-CM and ICD-10-CM codes during the transition between the code sets.
January 6, 2014- Medicare will begin accepting the new form.
January 6, 2014 through March 31, 2014- Medicare will accept both the old-style CMS 1500 and the new form.
April 1, 2014- Medicare, and very importantly ALL commercial payers, will accept the new form and the new form ONLY. Beginning on this date, using the old-style form will result in claim denials.

ICD-10 DEADLINE OCTOBER 1, 2014

The Division of Workers’ Compensation (DWC) has posted proposed changes to regulations reflecting transition from ICD-9 to ICD-10 to the online forum where members of the public may review and comment on the proposals.

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). ICD-10 is already in use in many countries. The United States continues to use ICD-9, the prior edition of ICD.

The deadline for the United States to begin using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding is currently October 1, 2014. In preparation for this deadline, it is necessary for the DWC to update regulations and forms to refer to ICD-10, rather than ICD-9. Affected regulations are 8 C.C.R. §§ 9702(e), 9770(g) and 9789.16.2(a).

Affected forms are DLSR 5021 (Doctor’s First Report of Injury), PR-2 (Primary Treating Physician’s Progress Report), PR-3 and PR-4 (Primary Treating Physician’s Permanent and Stationary Reports).

Medical Legal Experts is a group of Qualified Medical Evaluators (QME), Agreed Medical Evaluators (AME) and Medical-Legal Experts here to give you a fair and ethical examination with an accurate and complete impairment rating.

Medical Legal Experts is an approved provider of continuing education by the California Division of Workers’ Compensation (DWC) for Qualified Medical Evaluators (QME), the California Board of Chiropractic Examiners, the U.S. Federation of Chiropractic Examiners and Canadian Memorial Chiropractic College.

Qualified Medical Evaluators, QME, Agreed Medical Evaluators, AME, Medical-Legal Experts, FCE, Functional Capacity Evaluations, DWC, Workers’ Compensation, Work Comp, California.