| (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.
(11) V1, Level of MMI for Treating Doctor--This modifier
shall be added to CPT Code 99455 when the office visit level of service
is equal to a "minimal" level.
(12) V2, Level of MMI for Treating Doctor--This modifier
shall be added to CPT Code 99455 when the office visit level of service
is equal to "self limited or minor" level.
(13) V3, Level of MMI for Treating Doctor--This modifier
shall be added to CPT Code 99455 when the office visit level of service
is equal to "low to moderate" level.
(14) V4, Level of MMI for Treating Doctor--This modifier
shall be added to CPT Code 99455 when the office visit level of service
is equal to "moderate to high severity" level and of at least 25 minutes
duration.
(15) V5, Level of MMI for Treating Doctor--This modifier
shall be added to CPT Code 99455 when the office visit level of service
is equal to "moderate to high severity" level and of at least 45 minutes
duration.
(16) WC, Work Conditioning--This modifier shall be
added to CPT Code 97545 to indicate work conditioning was performed.
(17) WH, Work Hardening--This modifier shall be added
to CPT Code 97545 to indicate work hardening was performed.
(18) 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.
(19) W1, Case Management for Treating Doctor--This
modifier shall be added to the appropriate case management billing
code activities when performed by the treating doctor.
(20) W5, Designated Doctor Examination for Impairment
or Attainment of Maximum Medical Improvement--This modifier shall
be added to the appropriate examination code performed by a designated
doctor when determining impairment caused by the compensable injury
and in attainment of maximum medical improvement.
(21) W6, Designated Doctor Examination for Extent--This
modifier shall be added to the appropriate examination code performed
by a designated doctor when determining extent of the employee's compensable
injury.
(22) W7, Designated Doctor Examination for Disability--This
modifier shall be added to the appropriate examination code performed
by a designated doctor when determining whether the injured employee's
disability is a direct result of the work-related injury.
(23) W8, Designated Doctor Examination for Return to
Work--This modifier shall be added to the appropriate examination
code performed by a designated doctor when determining the ability
of employee to return to work.
(24) W9, Designated Doctor Examination for Other Similar
Issues--This modifier shall be added to the appropriate examination
code performed by a designated doctor when determining other similar
issues.
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