| (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:
(I) The examining doctor (e.g., the referring doctor)
shall bill using the appropriate MMI CPT code with modifier "SP" and
indicate one unit in the units column of the billing form. Reimbursement
shall be $50 for incorporating one or more specialists' report(s)
information into the final assignment of IR. This reimbursement shall
be allowed only once per examination.
(II) The referral specialist shall bill and be reimbursed
for the appropriate CPT code(s) for the tests required for the assignment
of IR. Documentation is required.
(iv) When there is no test to determine an IR for a
non-musculoskeletal condition:
(I) The IR is based on the charts in the AMA Guides.
These charts generally show a category of impairment and a range of
percentage ratings that fall within that category.
(II) The impairment rating doctor must determine and
assign a finite whole percentage number rating from the range of percentage
ratings.
(III) Use of these charts to assign an IR is equivalent
to assigning an IR by the DRE method as referenced in subparagraph
(C)(ii)(I) of this paragraph.
(v) The MAR for the assignment of an IR in a non-musculoskeletal
body area shall be $150.
(5) If the examination for the determination of MMI
and/or the assignment of IR requires testing that is not outlined
in the AMA Guides, the appropriate CPT code(s) shall be billed and
reimbursed in addition to the fees outlined in paragraphs (3) and
(4) of this subsection.
(6) The treating doctor is required to review the certification
of MMI and assignment of IR performed by another doctor, as stated
in the Act and Division Rules, Chapter 130 of this title. The treating
doctor shall bill using CPT Code 99455 with modifier "VR" to indicate
a review of the report only, and shall be reimbursed $50.
(k) The following shall apply to Return to Work (RTW)
and/or Evaluation of Medical Care (EMC) Examinations. When conducting
a Division or insurance carrier requested RTW/EMC examination, the
examining doctor shall bill and be reimbursed using CPT Code 99456
with modifier "RE." In either instance of whether MMI/IR is performed
or not, the reimbursement shall be $500 in accordance with subsection
(i) of this section and shall include Division-required reports. Testing
that is required shall be billed using the appropriate CPT codes and
reimbursed in addition to the examination fee.
(l) The following shall apply to Work Status Reports.
When billing for a Work Status Report that is not conducted as a part
of the examinations outlined in subsections (i) and (j) of this section,
refer to §129.5 of this title (relating to Work Status Reports).
(m) The following shall apply to Treating Doctor Examination
to Define the Compensable Injury. When billing for this type of examination,
refer to §126.14 of this title (relating to Treating Doctor Examination
to Define Compensable Injury).
(n) The following Division Modifiers shall be used
by HCPs billing professional medical services for correct coding,
reporting, billing, and reimbursement of the procedure codes.
(1) CA, Commission on Accreditation of Rehabilitation
Facilities (CARF) Accredited programs--This modifier shall be used
when a HCP bills for a Return To Work Rehabilitation Program that
is CARF accredited.
(2) CP, Chronic Pain Management Program--This modifier
shall be added to CPT Code 97799 to indicate Chronic Pain Management
Program services were performed.
(3) FC, Functional Capacity--This modifier shall be
added to CPT Code 97750 when a functional capacity evaluation is performed.
(4) MR, Outpatient Medical Rehabilitation Program--This
modifier shall be added to CPT Code 97799 to indicate Outpatient Medical
Rehabilitation Program services were performed.
(5) MI, Multiple Impairment Ratings--This modifier
shall be added to CPT Code 99455 when the designated doctor is required
to complete multiple impairment ratings calculations.
(6) NM, Not at Maximum Medical Improvement (MMI)--This
modifier shall be added to the appropriate MMI CPT code to indicate
that the injured employee has not reached MMI when the purpose of
the examination was to determine MMI.
(7) RE, Return to Work (RTW) and/or Evaluation of Medical
Care (EMC)--This modifier shall be added to CPT Code 99456 when a
RTW or EMC examination is performed.
(8) SP, Specialty Area--This modifier shall be added
to the appropriate MMI CPT code when a specialty area is incorporated
into the MMI report.
(9) TC, Technical Component--This modifier shall be
added to the CPT code when the technical component of a procedure
is billed separately.
(10) VR, Review report--This modifier shall be added
to CPT Code 99455 to indicate that the service was the treating doctor's
review of report(s) only.
Cont'd... |
