Current through Reg. 49, No. 38; September 20, 2024
(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.
