IWCC Approves 15% Fee Schedule Increase for Reimbursement of Evaluation and Management Codes

6.17.2022 Blog

On June 13, 2022, Chairman Michael Brennan of the Illinois Workers’ Compensation Commission (IWCC) signed an Order increasing the reimbursements for Evaluation and Management (E/M) codes by 15% across all Fee Schedule regions effective September 1, 2022.  This Order may likely result in increased medical costs for all claims, some more than others, and could lead to increased scrutiny over providers’ coding practices for E/M services.

The proposal has been discussed by the IWCC Medical Fee Advisory Board since it was proposed by board member, Dr. David Fletcher, in March 2020.  The issue had also been presented several years earlier and ultimately did not pass.  Dr. Fletcher’s original proposal would increase rates by 30%.

Access to care was the primary issue to be addressed by the rate increase.  In March 2021, Dr. Fletcher noted that the Illinois Fee Schedule rate was below Medicare reimbursement rates.  In April 2022, Dr. Fletcher amended the Motion to raise the reimbursement to 15%, rather than 30%, for 6 established CPT codes.

The Motion was passed by unanimous vote at the April 25, 2022, Medical Fee Advisory Board meeting.  The Motion was then presented to the IWCC Board at their June 13, 2022 meeting, and passed at that meeting.

Although Section 8.2 of the Illinois Workers’ Compensation Act provided a formula for setting the initial Fee Schedule rates, with annual rate increases based on the Consumer Price Index-U, Section 8.2(b) of the Act provides that “if the Commission finds that there is a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care, it may change the Consumer Price Index-U increase or decrease for that specific field or specific  geographic limitation on access to health care to address that limitation.”  The Order noted that inadequate reimbursement created a presumptive access to care issue and that increasing reimbursement would alleviate the issue.

The order increases reimbursements for CPT codes 99203, 99204, 99205, 99213, 99214 and 99215 by 15% effective September 1, 2022.  The obvious impact will be increased medical costs on claims.  Although individual office visits represent relatively minor costs when compared to higher cost services like surgeries, and may be less frequent compared to physical therapy, they are an essential aspect of any claim requiring medical treatment, and the visits can add up over time.

Whether the Order will result in increased access to care remains to be seen.  A possible side effect of the increase may be closer scrutiny by employers over a providers’ E/M billing and coding practices to confirm that providers are coding for the appropriate level of reimbursement.  While many providers already have a practice of outlining or documenting the basis for the billed code in their office notes and reports (such as time and level of complexity), we may also see providers increase the time spent with patients to attain a higher time-level of reimbursement or address additional issues to increase the level complexity.

Our office will continue to monitor these issues and potential impacts on medical costs in workers’ compensation claims.  In the meantime, if you have any questions regarding the Illinois Workers’ Compensation Fee Schedule, or any other workers’ compensation questions, the attorneys at Nyhan, Bambrick, Kinzie, & Lowry, P.C. are available to help at any time.

The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information.  Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.