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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 §134.250 of this
title, 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 §134.250 of this
title, 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 §134.235 of this
title, 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 §134.235 of this title, 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 §134.235 of this
title, 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 §134.235 of this title, 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 section:
(A)the first examination shall be reimbursed at 100
percent of the set fee outlined in §134.235 of this title;
(B)the second examination shall be reimbursed at 50
percent of the set fee outlined in §134.235 of this title; and
(C)subsequent examinations shall be reimbursed at
25 percent of the set fee outlined in §134.235 of this title.
The agency certifies that legal counsel has
reviewed the proposal and found it to be within the state agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on March 4, 2016
TRD-201601114 Marisa Lopez Wagley
Acting General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Earliest possible date of adoption: April 17, 2016
For further information, please call: (512) 804-4703
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