| (a) The total maximum allowable reimbursement (MAR)
for a maximum medical improvement (MMI) or impairment rating (IR)
examination is equal to the MMI evaluation reimbursement plus the
reimbursement for the body area or areas evaluated for the assignment
of an IR. The MMI or IR examination must include:
(1) the examination;
(2) consultation with the injured employee;
(3) review of the records and films;
(4) the preparation and submission of reports (including
the narrative report and responding to the need for further clarification,
explanation, or reconsideration), calculation tables, figures, and
worksheets; and
(5) tests used to assign the IR, as outlined in the
AMA Guides to the Evaluation of Permanent Impairment (AMA Guides),
as stated in the Labor Code and Chapter 130 of this title.
(b) Referred doctors must only bill and be reimbursed
for an MMI or IR examination if they are an authorized doctor in accordance
with the Labor Code and Chapter 130 and §180.23 of this title.
(1) If the referred doctor determines that MMI has
not been reached, the referred doctor must bill, and the insurance
carrier must reimburse, the MMI evaluation portion of the examination
in accordance with subsections (c)(1) and (c)(2) of this section.
The referred doctor must add modifier "NM."
(2) If the referred doctor determines that MMI has
been reached and there is no permanent impairment because the injury
was sufficiently minor and IR evaluation is not warranted, the referred
doctor must bill, and the insurance carrier must reimburse, only the
MMI evaluation portion of the examination in accordance with subsections
(c)(1) and (c)(2) of this section.
(3) If the referred doctor determines MMI has been
reached and an IR evaluation is performed, the referred doctor must
bill, and the insurance carrier must reimburse, both the MMI evaluation
and the IR examination portions of the examination in accordance with
subsection (c) of this section.
(c) The following applies for billing and reimbursement
of an MMI or IR evaluation by a referred doctor.
(1) CPT code. The referred doctor must bill using CPT
code 99456 with the appropriate modifier.
(2) MMI. MMI evaluations will be reimbursed at $449
adjusted per §134.210(b)(4).
(3) IR. For IR examinations, the referred doctor must
bill, and the insurance carrier must reimburse, the components of
the IR evaluation. Indicate the number of body areas rated in the
units column of the billing form.
(A) For musculoskeletal body areas, the referred doctor
may bill for a maximum of three body areas.
(i) Musculoskeletal body areas are:
(I) spine and pelvis;
(II) upper extremities and hands; and
(III) lower extremities (including feet).
(ii) For musculoskeletal body areas:
(I) the reimbursement for the first musculoskeletal
body area is $385 adjusted per §134.210(b)(4); and
(II) the reimbursement for each additional musculoskeletal
body area is $192 adjusted per §134.210(b)(4).
(B) For non-musculoskeletal body areas, the referred
doctor must bill, and the insurance carrier must reimburse, for each
non-musculoskeletal body area examined.
(i) Non-musculoskeletal body areas are:
(I) body systems;
(II) body structures (including skin); and
(III) mental and behavioral disorders.
(ii) For a complete list of body system and body structure
non-musculoskeletal body areas, refer to the appropriate AMA Guides.
(iii) The reimbursement for the assignment of an IR
in a non-musculoskeletal body area is $192 adjusted per §134.210(b)(4).
(d) If the examination for the determination of MMI
or the assignment of IR requires testing that is not outlined in the
AMA Guides, the referred doctor must bill, and the insurance carrier
must reimburse, the appropriate testing CPT code or codes according
to the applicable fee guideline in addition to the fees for the examination
by the referred doctor outlined in subsection (c) of this section.
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