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(II)previously been treating the injured employee, then the billing and reimbursement shall be as outlined for the treating doctor. (iv)The treating doctor is required to review the certification of MMI and assignment of IR performed by another doctor (other than the designated doctor) as required by Chapter 130 of this title. The treating doctor shall bill using the "Work related or medical disability examination by the treating physician..." CPT code with modifier "VR" to indicate a review of the report only, and shall be reimbursed $50.00. (G)A designated doctor shall bill for an MMI/IR examination using the "Work related or medical disability examination by other than the treating physician..." CPT code with the appropriate modifier. (i)Reimbursement for the determination of MMI shall be based on the amount of time that has elapsed since the date of injury (DOI). One of the following modifiers shall be added to the MMI/IR examination CPT code: (I)D1 (less than one year since the DOI) - $200.00 (II)D2 (greater than or equal to one year and less than two years since the DOI) - $300.00 (III)D3 (greater than or equal to two years since the DOI) - $400.00 (ii)Reimbursement for the determination of an IR shall be according to the areas rated. If the testing is performed by a HCP other than the designated doctor, then to qualify for reimbursement, the testing HCP shall: (I)not have previously examined or treated the injured employee within the past 12 months, or with regard to the medical condition being evaluated by the designated doctor; and, (II)have successfully completed commission-approved training in the proper use of the Guides. (iii)Appointments canceled or not attended by the injured employee, with less than 24 hours notice to the designated doctor, shall be billed using the MMI/IR examination CPT code with modifier "BA" and the reimbursement shall be $100.00. (H)A doctor performing a Required Medical Examination (RME) for the purpose of certifying MMI and assigning an IR shall bill using the "Unlisted evaluation and management service" CPT code with the appropriate modifier. (i)Reimbursement for the determination of MMI shall be based on the amount of time that has elapsed since the date of injury (DOI). One of the following modifiers shall be added to the MMI/IR CPT code: (I)R1 (first RME if less than one year from DOI or any subsequent RMEs) - $100.00 (II)R2 (first RME if greater than or equal to one year and less than two years since the DOI) - $200.00 (III)R3 (first RME if greater than or equal to two years since the DOI) - $300.00 (ii)Reimbursement for the determination of an IR shall be according to the areas rated. (iii)Appointments scheduled by the commission and canceled or not attended by the injured employee, with less than 24 hours notice to the doctor, shall be billed using the MMI/IR CPT code with modifier "BA" and the reimbursement shall be $100.00. (iv)An injured employee's treating doctor attending an RME shall bill using the "Unlisted evaluation and management service" CPT code with modifier "AR." Reimbursement shall be $25.00 per 15-minute increment (any amount over ten minutes shall be considered an additional 15 minute increment). Reimbursement includes the duration of the examination and the time required to travel to and from the treating doctor's usual place of business to the place of examination. A maximum of four hours shall be allowed, unless the insurance carrier previously approved extended time. (7)Return to Work Exam. When a designated doctor is appointed by the commission to perform an examination to resolve a return to work dispute, the designated doctor shall bill using the "Work related or medical disability examination by other than the treating physician..." CPT code with modifier "RW." The reimbursement shall be $350.00 and shall include commission-required reports. Testing that is required for the return to work determination shall be billed using the appropriate CPT codes and reimbursed in addition to the return to work examination fee. Appointments scheduled by the commission and canceled or not attended by the injured employee, with less than 24 hours notice to the designated doctor, shall be billed using the "Work related or medical disability examination by other than the treating physician..." CPT code with modifier "BA" and the reimbursement shall be $100.00. (8)Evaluation of Medical Care Exam. When conducting a commission or insurance carrier requested RME that is not for the purpose of certifying MMI and/or assigning an IR (e.g. evaluation of medical care), the examining doctor shall bill and be reimbursed using the appropriate consultation CPT code with modifier "RM." Appointments scheduled by the commission and canceled or not attended by the injured employee with less than 24 hours notice to the HCP shall be billed using the "Unlisted special service, procedure or report" CPT code with modifier "BA," and reimbursement shall be $50.00. (9)Work Status Report. When billing for a Work Status Report refer to the commission Act and Rules Chapter 129 relating to Income Benefits - Temporary Income Benefits. (10)Commission Modifiers. HCPs billing professional medical services shall utilize the following modifiers, in addition to the modifiers prescribed by the Medicare policies required to be used in subsection (b) of this section, for correct coding, reporting, billing, and reimbursement of the procedure codes. (A)AR, Treating Doctor Attendance at RME - This modifier shall be added to the "Unlisted evaluation and management service" CPT code to indicate an injured employee's treating doctor attended an RME. (B)BA, Broken Appointment - This modifier shall be added to the appropriate CPT code when appointments scheduled by the commission are canceled or not attended by the injured employee, with less than 24 hours notice to the HCP. (C)CA, Commission of Accreditation of Rehabilitation Facilities (CARF) Accredited programs - This modifier shall be used when an HCP bills for a Return To Work Rehabilitation Program that is CARF accredited. (D)CP, Chronic Pain Management Program - This modifier shall be added to the "Unlisted physical medicine/rehabilitation service or procedure" CPT code to indicate Chronic Pain Management Program services were performed. (E)D1, Time of MMI/IR for Designated Doctor - This modifier shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code when the amount of time that has elapsed since the date of injury is less than one year. (F)D2, Time of MMI/IR for Designated Doctor - This modifier shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to one year and less than two years. (G)D3, Time of MMI/IR for Designated Doctor - This modifier shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to two years. (H)FC, Functional Capacity - This modifier shall be added to the "Physical performance test or measurement..." CPT code when a functional capacity evaluation is performed. (I)JA, Job Site Analysis/Assessment - This modifier shall be added to the "Community/work reintegration training..." CPT code when a job site visit/assessment is performed. (J)MR, Outpatient Medical Rehabilitation Program - This modifier shall be added to the "Unlisted physical medicine/rehabilitation service or procedure" CPT code to indicate Outpatient Medical Rehabilitation Program services were performed. (K)NM, Not at Maximum Medical Improvement (MMI) - This modifier shall be added to the appropriate MMI/IR CPT code to indicate that the injured employee has not reached MMI when the purpose of the exam was to determine MMI. (L)RM, Required Medical Examination to Evaluate Medical Care - This modifier shall be added to the appropriate consultation CPT code to indicate an RME not for the purpose of certifying MMI or assessing an IR has been performed. (M)RW, Required Return-to-Work Exam - This modifier shall be added to the "Work related or medical disability examination by other than the treating physician..." CPT code when a designated doctor is appointed by the commission to perform an examination to resolve return to work disputes. (N)R1, Time of MMI/IR for RME Doctor - This modifier shall be added to the "Unlisted evaluation and management service" CPT code when the amount of time that has elapsed since the date of injury is less than one year; or, for any subsequent RMEs. (O)R2, Time of MMI/IR for RME Doctor - This modifier shall be added to the "Unlisted evaluation and management service" CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to one year and less than two years. (P)R3, Time of MMI/IR for RME Doctor - This modifier shall be added to the "Unlisted evaluation and management service" CPT code when the amount of time that has elapsed since the date of injury is greater than or equal to two years. (Q)SP, Specialty Area - This modifier shall be added to the appropriate MMI/IR CPT code when a specialty area is incorporated into the MMI/IR report. (R)TC, Technical Component - This modifier shall be added to the CPT code when the technical component of a procedure is billed separately. (S)VR, Review report - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code to indicate that the service was the treating doctor's review of report(s) only. (T)V1, Level of MMI for Treating Doctor - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to a "minimal" level. (U)V2, Level of MMI for Treating Doctor - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "self limited or minor" level. (V)V3, Level of MMI for Treating Doctor - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "low to moderate" level. (W)V4, Level of MMI for Treating Doctor - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "moderate to high severity" level and of at least 25 minutes duration. (X)V5, Level of MMI for Treating Doctor - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code when the office visit level of service is equal to "moderate to high severity" level and of at least 45 minutes duration. (Y)WC, Work Conditioning - This modifier shall be added to the "Work hardening/conditioning" CPT code to indicate work conditioning was performed. (Z)WH, Work Hardening - This modifier shall be added to the "Work hardening/conditioning" CPT code to indicate work hardening was performed. (AA) WP, Whole Procedure - This modifier shall be added to the CPT code when both the professional and technical components of a procedure are performed by a single HCP. (f)Where any terms or parts of this section or its application to any person or circumstance are determined by a court of competent jurisdiction to be invalid, the invalidity does not affect other provisions or applications of this section that can be given effect without the invalidated provision or application.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on December 14, 2001
TRD-200107941 Susan
Cory
General Counsel
Texas Workers' Compensation Commission
Earliest possible date of adoption: January 27, 2002
For further information, please call: (512) 804-4287
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