1.3 Diagnostic and Evaluation Services

(Procedure codes 01000-01, 01000-02, 01100-01, 01100-02, 01100-03, 01100-04, 01400-02, 01400-03, 01400-04, 01500-02, 01500-03, 01500-04, 01600-03, 01600-04, 01600-05, 01600-06, 01900-01, 01900-02, 01900-03, 01900-04, 01900-05, 01900-06, 01900-07, 11000-07, 11000-08)

CPT codes used for diagnostic medical procedures are frequently found in either the “Medicine” section or the “Evaluation and Management” section of the RVP. Medical assessments or diagnostic tests ordered in conjunction with a specialty examination are typically found in the “Medicine” section. Unless prohibited by a procedure’s description, the physician may also be paid for the office visit, which is reported as an “Evaluation and Management” procedure.

The “Evaluation and Management” section of the RVP contains two series of CPT codes (i.e., new patient or established patient) that depend on the physician’s previous knowledge of the individual, the type of medical history required, the scope of the required physical examination, the complexity of medical decision-making required of the physician, and the detailed reporting of medical and work-related functional limitations necessary.

(Procedure codes 01300-01, 01300-02—non-dental)

Diagnostic services provided to establish an impairment must be ordered by a licensed physician. The services must be provided by a laboratory that is certified in accordance with the Clinical Laboratory Improvement Amendments of 1988 or meets the Health Care Financing Administration guidelines; or by an independent laboratory certified by the Health Facilities Division of the Colorado Department of Public Health and Environment.

Diagnostic services will be purchased from independent laboratories only in the specialties or sub-specialties for which they are certified. Laboratories that provide X-ray services must have their X-ray equipment, directors, and equipment operators certified by the Colorado Department of Health as meeting Medicare guidelines.

The fees for radiological diagnostic procedures are frequently separated into two components. The “technical component” (modifier TC) covers the cost of equipment, supplies, technical personnel, and other incidental expenses. This component is allowed when the service is provided to an outpatient by an appropriately certified laboratory. Payment of a “professional component” (modifier 26) is also allowed to compensate the radiologist for supervision of the laboratory’s activities and interpretation of the radiological studies, when required. Alternatively, both components can be billed in total with a modifier of 00.

In addition, the CPT coding structure lists tests in groups at a lower cost than individual tests. When tests are ordered in a group, the individual tests will not be paid for separately. Conversely, when the physician orders multiple individual tests that can be performed in a group, the maximum-allowable fee corresponds to the CPT code for such tests in a group. Laboratory procedures are generally found in the “Radiology” or “Pathology” sections of the RVP.

(Procedure codes 01700-07, 01700-08)

This service is to assess the extent of hearing loss includes the complete audiologic history, full diagnostic evaluation including pure-tone and bone conduction testing, speech discrimination, tympanometry, and acoustic reflex testing, and full report to DVR.

(Procedure codes 05000-01, 05000-02, 05000-07, 05000-08, 05000-10, 05100-01, 05100-02, 05100-03, 05100-04, 05200-01, 05200-02, 05200-03, 05200-08, 05300-02, 05300-03, 05900-08, 05900-09, 05900-10, 05900-11, 05900-12, 05900-13)

Licensed neuropsychologists, psychologists, psychiatrists, or certified learning disability specialists administer evaluations and interpret and report results. Types of assessments are found in the “Medicine” section of the RVP, CPT codes 90791-90792, 90885-90889, and 96101- 96150. The total allowable fee for such tests depends upon the amount of time required. The CPT code series 99212-99215, found in the “Evaluation and Management” section of the RVP, is used if a follow-up diagnostic session is necessary.