| (a) Designated doctors must perform examinations in
accordance with Labor Code §§408.004, 408.0041, and 408.151
and division rules.
(b) The designated doctor must bill, and the insurance
carrier must reimburse, for a missed appointment when the injured
employee does not attend a properly scheduled or rescheduled examination
under 28 TAC §127.5(h) - (j).
(1) The designated doctor may bill for the missed appointment
fee when:
(A) the injured employee does not attend a scheduled
appointment; and
(B) the designated doctor waits at the examination
location for at least 30 minutes after the scheduled appointment time.
(2) When billing for the missed appointment, the designated
doctor must bill CPT code 99456 with modifier "52."
(3) Reimbursement for a missed appointment is $100
adjusted per §134.210(b)(4).
(4) Reimbursement for a missed appointment under this
section does not qualify for the 10% incentive payment under §134.2
of this chapter.
(c) Each examination and its individual billable components
will be billed and reimbursed separately.
(d) When conducting a designated doctor examination,
the designated doctor must bill, and the insurance carrier must reimburse,
using CPT code 99456 and with the modifiers and rates specified in
subsections (d)(1) - (7).
(1) 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:
(A) the examination;
(B) consultation with the injured employee;
(C) review of the records and films;
(D) 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
(E) tests used to assign the IR, as outlined in the
American Medical Association Guides to the Evaluation of Permanent
Impairment (AMA Guides), as stated in the Labor Code and Chapter 130
of this title.
(2) A designated doctor 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.
(A) If the designated doctor determines that MMI has
not been reached, the MMI evaluation portion of the examination must
be billed and reimbursed in accordance with subsection (d) of this
section. The designated doctor must add modifier "NM."
(B) If the designated doctor determines that MMI has
been reached and there is no permanent impairment because the injury
was sufficiently minor, an IR evaluation is not warranted and only
the MMI evaluation portion of the examination must be billed and reimbursed
in accordance with subsection (d) of this section.
(C) If the designated doctor determines MMI has been
reached and an IR evaluation is performed, both the MMI evaluation
and the IR evaluation portions of the examination must be billed and
reimbursed in accordance with subsection (d) of this section.
(3) MMI. MMI evaluations will be reimbursed at $449
adjusted per §134.210(b)(4), and the designated doctor must apply
the additional modifier "W5."
(4) IR. For IR examinations, the designated doctor
must bill, and the insurance carrier must reimburse, the components
of the IR evaluation. The designated doctor must apply the additional
modifier "W5." Indicate the number of body areas rated in the units
column of the billing form.
(A) For musculoskeletal body areas, the designated
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 designated
doctor must bill, and the insurance carrier must reimburse, for each
non-musculoskeletal body area examined.
(i) Non-musculoskeletal body areas are defined as follows:
(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).
(iv) The test or tests required by Chapter 127 of this
title for the assignment of IR, as outlined in the AMA Guides, must
be billed using the appropriate CPT code or codes and reimbursed under
the applicable division fee guideline in addition to the fees outlined
in subsection (b) and (d)(1) - (3) of this section.
(C) If the examination for the determination of MMI
or the assignment of IR requires testing authorized by Chapter 127
of this title that is not outlined in the AMA Guides, the appropriate
CPT code or codes must be billed, and the insurance carrier must reimburse,
according to the applicable division fee guideline, in addition to
the fees outlined in subsections (d)(1) - (3) and (d)(4)(A) - (B)
of this section.
(D) When multiple IRs are required as a component of
a designated doctor examination under this title, the designated doctor
must bill for the number of body areas rated, and the insurance carrier
must reimburse, $64 adjusted per §134.210(b)(4) for each additional
IR calculation.
(E) When the division requires the designated doctor
to complete multiple IR calculations, the designated doctor must apply
the additional modifier "MI."
(5) Extent of injury. The reimbursement rate for determining
the extent of the employee's compensable injury is $642 adjusted per §134.210(b)(4),
and the designated doctor must apply the additional modifier "W6."
(6) Disability. The reimbursement rate for determining
whether the injured employee's disability is a direct result of the
work-related injury is $642 adjusted per §134.210(b)(4), and
the designated doctor must apply the additional modifier "W7."
(7) Return to work. The reimbursement rate for determining
the ability of the injured employee to return to work is $642 adjusted
per §134.210(b)(4), and the designated doctor must apply the
additional modifier "W8."
(8) Other similar issues. The reimbursement rate for
determining other similar issues is $642 adjusted per §134.210(b)(4),
and the designated doctor must apply the additional modifier "W9"
when examining issues similar to those described in subsection (d)(1)
- (6).
(e) Required testing or evaluation under §127.10
of this title must be billed using the appropriate CPT codes. Reimbursement
will be according to §134.203 or other applicable division fee
guideline in addition to the examination fee. If a designated doctor
refers an injured employee for additional testing or evaluation under §127.10
of this title:
(1) The 95-day period for timely submission of the
designated doctor bill for the examination begins on the date of service
of the additional testing or evaluation.
(2) The dates of service (CMS-1500/field 24A) are as
follows: the "From" date is the date of the designated doctor examination,
and the "To" date is the date of service of the additional testing
or evaluation.
(3) The designated doctor and any referral health care
providers must include the DWC-provided assignment number in the prior
authorization field (CMS-1500/field 23) in accordance with §133.10(f)(1)(N).
(f) When the designated doctor refers an injured employee
to a specialist for additional testing or evaluation under §127.10
of this title, the referral health care provider must bill:
(1) using the appropriate CPT codes, and the insurance
carrier must reimburse, according to §134.203 or other applicable
division fee guideline in addition to the examination fee;
(2) using the assignment number provided by the designated
doctor; and
(3) attaching the required documentation.
(g) When the division orders the designated doctor
to perform an examination of an injured employee with one or more
of the diagnoses listed in §127.130(b)(9)(B) - (I) of this title:
(1) The designated doctor must add modifier "25" to
the appropriate examination code.
(2) The designated doctor must add modifier "25" once
per bill when addressing issues on the same day, regardless of the
number of diagnoses or the number of issues the division ordered the
designated doctor to examine.
(3) The designated doctor must bill, and the insurance
carrier must reimburse, $300 adjusted per §134.210(b)(4) in addition
to the examination fee.
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