Current through Reg. 49, No. 38; September 20, 2024
(a) The total
maximum allowable reimbursement (MAR) for a maximum medical improvement (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:
(1) the examination;
(2) consultation with the injured
employee;
(3) review of the records
and films;
(4) 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
(5) tests used to assign the IR, as outlined
in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), as
stated in the Labor Code and Chapter 130 of this title.
(b) Referred 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.
(1) If the referred doctor determines that
MMI has not been reached, the referred doctor must bill, and the insurance
carrier must reimburse, the MMI evaluation portion of the examination in
accordance with subsection (c)(1) and (2) of this section. The referred doctor
must add modifier "NM."
(2) If the
referred doctor determines that MMI has been reached and there is no permanent
impairment because the injury was sufficiently minor and IR evaluation is not
warranted, the referred doctor must bill, and the insurance carrier must
reimburse, only the MMI evaluation portion of the examination in accordance
with subsection (c)(1) and (2) of this section.
(3) If the referred doctor determines MMI has
been reached and an IR evaluation is performed, the referred doctor must bill,
and the insurance carrier must reimburse, both the MMI evaluation and the IR
examination portions of the examination in accordance with subsection (c) of
this section.
(c) The
following applies for billing and reimbursement of an MMI or IR evaluation by a
referred doctor.
(1) CPT code. The referred
doctor must bill using CPT code 99456 with the appropriate modifier.
(2) MMI. MMI evaluations will be reimbursed
at $449 adjusted per §134.210(b)(4).
(3) IR. For IR examinations, the referred
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 referred 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
referred doctor must 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).
(d) If the examination for the determination
of MMI or the assignment of IR requires testing that is not outlined in the AMA
Guides, the referred 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
referred doctor outlined in subsection (c) of this section.
