| (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) Treating doctors must only bill and be reimbursed
for an MMI and 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 treating doctor determines that MMI has
not been reached, the treating 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.
(2) If the treating doctor determines MMI has been
reached and there is no permanent impairment because the injury was
sufficiently minor, an IR evaluation is not warranted and the treating
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 treating doctor determines MMI has been
reached and an IR evaluation is performed, the treating doctor must
bill, and the insurance carrier must reimburse, both the MMI evaluation
and the IR evaluation portions of the examination in accordance with
subsection (c) of this section.
(4) If the treating doctor is not authorized to assign
an IR, the treating doctor may refer the injured employee to an authorized
doctor for the examination and certification of MMI and IR. The referred
doctor must bill under §134.260 of this chapter.
(c) The following applies for billing and reimbursement
of an MMI or IR evaluation by a treating doctor.
(1) CPT code. The treating doctor must bill using CPT
code 99455 with the appropriate modifier. Modifiers "V3," "V4," or
"V5" must be added to CPT code 99455 to correspond with the last digit
of the applicable office visit.
(2) MMI. MMI evaluations must be reimbursed based on
the applicable established patient office visit level associated with
the examination under §134.203 of this chapter.
(3) IR. For IR examinations, the treating 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 treating 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 treating
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).
(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 treating 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 treating doctor outlined in subsection (c) of this section.
(e) The treating doctor is required to review the certification
of MMI and assignment of IR performed by another doctor, as stated
in the Labor Code and Chapter 130 of this title. The treating doctor
must bill using CPT code 99455 with modifier "VR" to indicate a review
of the report only, and the insurance carrier must reimburse $64 adjusted
per §134.210(b)(4).
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