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(a)Required medical examination doctors (RME doctors)
must perform examinations in accordance with Labor Code §§408.004,
408.0041, 408.0043, and 408.0045 and division rules.
(b)Each examination and its individual billable components
will be billed and reimbursed separately.
(c)When conducting an insurance carrier-requested
examination to determine impairment or attainment of maximum medical
improvement (MMI), the RME doctor must bill, and the insurance carrier
must reimburse, using CPT code 99456, with the modifiers and at the
rates specified in paragraphs (c)(2) - (3).
(1)The total maximum allowable reimbursement (MAR)
for a MMI or impairment rating (IR) examination is equal to the MMI
evaluation reimbursement plus the reimbursement for the body area
or areas evaluated for the assignment of an IR. The MMI or IR examination
must 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
American Medical Association Guides to the Evaluation of Permanent
Impairment (AMA Guides), as stated in the Labor Code and Chapter 130
of this title.
(2)RME doctors must only bill and be reimbursed for
an MMI or IR examination if they are an authorized doctor in accordance
with the Labor Code and Chapter 130 and §180.23 of this title.
(A)If the RME doctor determines that MMI has not been
reached, the RME doctor must bill, and the insurance carrier must
reimburse, the MMI evaluation portion of the examination in accordance
with subsections (c)(1) and (c)(3) of this section. The RME doctor
must add modifier "NM."
(B)If the RME doctor determines that MMI has been
reached and there is no permanent impairment because the injury was
sufficiently minor, and an IR evaluation was not warranted, the RME
doctor must only bill, and the insurance carrier must only reimburse,
the MMI evaluation portion of the examination in accordance with subsections
(c)(1) and (c)(3) of this section.
(C)If the RME doctor determines MMI has been reached
and an IR evaluation is performed, the RME doctor must bill, and the
insurance carrier must reimburse, both the MMI evaluation and the
IR evaluation portions of the examination in accordance with this
subsection.
(3)MMI. MMI evaluations will be reimbursed at $449
adjusted per §134.210(b)(4).
(4)IR. For IR examinations, the RME doctor must bill,
and the insurance carrier must reimburse, the components of the IR
evaluation. Indicate the number of body areas rated in the units column
of the billing form.
(A)For musculoskeletal body areas, the RME doctor
may bill for a maximum of three body areas.
(i)Musculoskeletal body areas are:
(I)spine and pelvis;
(II)upper extremities and hands; and
(III)lower extremities (including feet).
(ii)For musculoskeletal body areas:
(I)the reimbursement for the first musculoskeletal
body area is $385 adjusted per §134.210(b)(4); and
(II)the reimbursement for each additional musculoskeletal
body area is $192 adjusted per §134.210(b)(4).
(B)For non-musculoskeletal body areas, the RME doctor
may bill, and the insurance carrier must reimburse, for each non-musculoskeletal
body area examined.
(i)Non-musculoskeletal body areas are:
(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)The reimbursement for the assignment of an IR
in a non-musculoskeletal body area is $192 adjusted per §134.210(b)(4).
(C)If the examination for the determination of MMI
or the assignment of IR requires testing that is not outlined in the
AMA Guides, the RME doctor must bill, and the insurance carrier must
reimburse, the appropriate testing CPT code or codes according to
the applicable fee guideline in addition to the fees for the examination
by the RME doctor outlined in subsection (c) of this section.
(d)When conducting an insurance carrier-requested
examination to determine the extent of the employee's compensable
injury, whether the injured employee's disability is a direct result
of the compensable injury, the ability of the injured employee to
return to work, other similar issues, or appropriateness of medical
care, the RME doctor must bill, and the insurance carrier must reimburse,
using CPT code 99456 and at the rates specified in paragraphs (d)(1)
- (5).
(1)Extent of injury. The reimbursement rate for determining
the extent of the injured employee's compensable injury is $642 adjusted
per §134.210(b)(4).
(2)Disability. The reimbursement rate for determining
whether the injured employee's disability is a direct result of the
work-related injury is $642 adjusted per §134.210(b)(4).
(3)Return to work. The reimbursement rate for determining
the ability of the injured employee to return to work is $642 adjusted
per §134.210(b)(4).
(4)Other similar issues. The reimbursement rate for
determining other similar issues is $642 adjusted per §134.210(b)(4).
(5)Appropriateness of health care. The reimbursement
rate for appropriateness of health care as defined in §126.6
(concerning Required Medical Examination) and Labor Code §408.004
is $642 adjusted per §134.210(b)(4).
(e)When the RME doctor refers testing to a specialist,
the referral health care provider must bill, and the insurance carrier
must reimburse, the appropriate CPT code or codes for the tests required
for the assignment of IR, according to the applicable division fee
guideline. Documentation of the referral is required.
The agency certifies that legal counsel has reviewed
the adoption and found it to be a valid exercise of the agency's legal
authority.
Filed with the Office
of the Secretary of State on February 23, 2024
TRD-202400816 Kara Mace
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Effective date: June 1, 2024
Proposal publication date: December 29, 2023
For further information, please call: (512) 804-4703
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