| (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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