California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 5.3 - Official Medical Fee Schedule
Section 9789.12.12 - Consultation Services Coding - Use of Visit Codes

Universal Citation: 8 CA Code of Regs 9789.12.12

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Maximum fees for physicians and qualified non-physician practitioners performing consultation services shall be determined utilizing the appropriate RVU for a patient evaluation and management visit and the RVU(s) for prolonged service codes if warranted under CPT guidelines. Physicians and qualified non-physician practitioners shall code consultation visits as patient evaluation and management visits utilizing the CPT Evaluation and Management codes that represent where the visit occurs and that correspond to the level of the visit performed. CPT consultation codes shall not be utilized.

(1) In the inpatient hospital setting and the nursing facility setting consulting physicians (and qualified non-physician practitioners where permitted) who perform an initial evaluation may bill the initial hospital inpatient or observation care codes (99221 -- 99223) or nursing facility care codes (99304 -- 99306).

Follow-up consultation visits in the inpatient hospital setting shall be billed as subsequent hospital inpatient or observation care visits (99231 -- 99233) and subsequent nursing facility care visits (99307 -- 99310.)

(2) In the office or other outpatient setting where a consultation / evaluation is performed, physicians and qualified non-physician practitioners shall use the CPT visit codes (99202 -- 99215) that correspond to the level of the visit and based upon whether the patient is a new or established patient to that physician, as defined in section 9789.12.11.

(b) Consultation reports are bundled into the underlying evaluation and management visit code or hospital care code, and are not separately payable, except as specified in subdivision (c).

(1) Consultation reports requested by the Workers' Compensation Appeals Board or the Administrative Director. Use WC007, modifier -32.

(2) Consultation reports requested by the Qualified Medical Evaluator ("QME") or Agreed Medical Evaluator ("AME") in the context of a medical-legal evaluation. Use WC007, modifier -30.

Note: Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

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