| (B) Reimbursement shall be $125 per hour. Units of
less than one hour shall be prorated in 15 minute increments. A single
15 minute increment may be billed and reimbursed if greater than or
equal to eight minutes and less than 23 minutes.
(i) The following shall apply to Designated Doctor
Examinations.
(1) Designated Doctors shall perform examinations in
accordance with Labor Code §§408.004, 408.0041 and 408.151
and Division rules, and shall be billed and reimbursed as follows:
(A) Impairment caused by the compensable injury shall
be billed and reimbursed in accordance with subsection (j) of this
section, and the use of the additional modifier "W5" is the first
modifier to be applied when performed by a designated doctor;
(B) Attainment of maximum medical improvement shall
be billed and reimbursed in accordance with subsection (j) of this
section, and the use of the additional modifier "W5" is the first
modifier to be applied when performed by a designated doctor;
(C) Extent of the employee's compensable injury shall
be billed and reimbursed in accordance with subsection (k) of this
section, with the use of the additional modifier "W6";
(D) Whether the injured employee's disability is a
direct result of the work-related injury shall be billed and reimbursed
in accordance with subsection (k) of this section, with the use of
the additional modifier "W7";
(E) Ability of the employee to return to work shall
be billed and reimbursed in accordance with subsection (k) of this
section, with the use of the additional modifier "W8"; and
(F) Issues similar to those described in subparagraphs
(A) - (E) of this paragraph shall be billed and reimbursed in accordance
with subsection (k) of this section, with the use of the additional
modifier "W9."
(2) When multiple examinations under the same specific
Division order are performed concurrently under paragraph (1)(C) -
(F) of this subsection:
(A) the first examination shall be reimbursed at 100
percent of the set fee outlined in subsection (k) of this section;
(B) the second examination shall be reimbursed at 50
percent of the set fee outlined in subsection (k) of this section;
and
(C) subsequent examinations shall be reimbursed at
25 percent of the set fee outlined in subsection (k) of this section.
(j) Maximum Medical Improvement and/or Impairment Rating
(MMI/IR) examinations shall be billed and reimbursed as follows:
(1) The total MAR for an MMI/IR examination shall be
equal to the MMI evaluation reimbursement plus the reimbursement for
the body area(s) evaluated for the assignment of an IR. The MMI/IR
examination shall 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
AMA Guides to the Evaluation of Permanent Impairment (AMA Guides),
as stated in the Act and Division rules in Chapter 130 of this title
(relating to Impairment and Supplemental Income Benefits).
(2) An HCP shall only bill and be reimbursed for an
MMI/IR examination if the doctor performing the evaluation (i.e.,
the examining doctor) is an authorized doctor in accordance with the
Act and Division rules in Chapter 130 of this title.
(A) If the examining doctor, other than the treating
doctor, determines MMI has not been reached, the MMI evaluation portion
of the examination shall be billed and reimbursed in accordance with
paragraph (3) of this subsection. Modifier "NM" shall be added.
(B) If the examining 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 only the
MMI evaluation portion of the examination shall be billed and reimbursed
in accordance with paragraph (3) of this subsection.
(C) If the examining doctor determines MMI has been
reached and an IR evaluation is performed, both the MMI evaluation
and the IR evaluation portions of the examination shall be billed
and reimbursed in accordance with paragraphs (3) and (4) of this subsection.
(3) The following applies for billing and reimbursement
of an MMI evaluation.
(A) An examining doctor who is the treating doctor
shall bill using CPT Code 99455 with the appropriate modifier.
(i) Reimbursement shall be the applicable established
patient office visit level associated with the examination.
(ii) Modifiers "V1", "V2", "V3", "V4", or "V5" shall
be added to the CPT code to correspond with the last digit of the
applicable office visit.
(B) If the treating doctor refers the injured employee
to another doctor for the examination and certification of MMI (and
IR); and, the referral examining doctor has:
(i) previously been treating the injured employee,
then the referral doctor shall bill the MMI evaluation in accordance
with paragraph (3)(A) of this subsection; or,
(ii) not previously treated the injured employee, then
the referral doctor shall bill the MMI evaluation in accordance with
paragraph (3)(C) of this subsection.
(C) An examining doctor, other than the treating doctor,
shall bill using CPT Code 99456. Reimbursement shall be $350.
(4) The following applies for billing and reimbursement
of an IR evaluation.
(A) The HCP shall include billing components of the
IR evaluation with the applicable MMI evaluation CPT code. The number
of body areas rated shall be indicated in the units column of the
billing form.
(B) When multiple IRs are required as a component of
a designated doctor examination under §130.6 of this title (relating
to Designated Doctor Examinations for Maximum Medical Improvement
and/or Impairment Ratings), the designated doctor shall bill for the
number of body areas rated and be reimbursed $50 for each additional
IR calculation. Modifier "MI" shall be added to the MMI evaluation
CPT code.
(C) For musculoskeletal body areas, the examining doctor
may bill for a maximum of three body areas.
(i) Musculoskeletal body areas are defined as follows:
(I) spine and pelvis;
(II) upper extremities and hands; and,
(III) lower extremities (including feet).
(ii) The MAR for musculoskeletal body areas shall be
as follows.
(I) $150 for each body area if the Diagnosis Related
Estimates (DRE) method found in the AMA Guides 4th edition is used.
(II) If full physical evaluation, with range of motion,
is performed:
(-a-) $300 for the first musculoskeletal body area;
and
(-b-) $150 for each additional musculoskeletal body
area.
(iii) If the examining doctor performs the MMI examination
and the IR testing of the musculoskeletal body area(s), the examining
doctor shall bill using the appropriate MMI CPT code with modifier
"WP." Reimbursement shall be 100 percent of the total MAR.
(iv) If, in accordance with §130.1 of this title
(relating to Certification of Maximum Medical Improvement and Evaluation
of Permanent Impairment), the examining doctor performs the MMI examination
and assigns the IR, but does not perform the range of motion, sensory,
or strength testing of the musculoskeletal body area(s), then the
examining doctor shall bill using the appropriate MMI CPT code with
CPT modifier "26." Reimbursement shall be 80 percent of the total
MAR.
(v) If a HCP, other than the examining doctor, performs
the range of motion, sensory, or strength testing of the musculoskeletal
body area(s), then the HCP shall bill using the appropriate MMI CPT
code with modifier "TC." In accordance with §130.1 of this title,
the HCP must be certified. Reimbursement shall be 20 percent of the
total MAR.
(D) Non-musculoskeletal body areas shall be billed
and reimbursed using the appropriate CPT code(s) for the test(s) required
for the assignment of IR.
(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) When the examining doctor refers testing for
non-musculoskeletal body area(s) to a specialist, then the following
shall apply:
Cont'd... |
