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 5.6 - Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations › Section 9795 - Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The schedule of
					 fees set forth in this section shall be prima facie evidence of the
					 reasonableness of fees charged for medical-legal evaluation reports, and fees
					 for medical-legal testimony. Reports by treating or consulting physicians,
					 other than comprehensive, follow-up or supplemental medical-legal evaluations,
					 regardless of whether liability for the injury has been accepted at the time
					 the treatment was provided or the report was prepared, shall be subject to the
					 Official Medical Fee Schedule adopted pursuant to Labor Code Section
					 5307.1 rather
					 than to the fee schedule set forth in this section.
(b) The fee for each evaluation is calculated
					 by multiplying the relative value by $16.25, and adding any amount applicable
					 because of the modifiers permitted under subdivision (d). The fee for each
					 medical-legal evaluation procedure includes reimbursement for the history and
					 physical examination, review of records, preparation of a medical-legal report,
					 including typing and transcription services, and overhead expenses. The
					 complexity of the evaluation is the dominant factor determining the appropriate
					 level of service under this section; the times to perform procedures is
					 expected to vary due to clinical circumstances, and is therefore not the
					 controlling factor in determining the appropriate level of service.
(c) Medical-legal evaluation reports and
					 medical-legal testimony shall be reimbursed as follows:
CODE
RV
PROCEDURE
								DESCRIPTION
ML200
31
Missed Appointment
								for a Comprehensive or
($503.75)
Follow-Up Medical-Legal
								Evaluation
.
Includes instances where the
								injured worker does not show up for the evaluation, the interpreter does not
								show up for the evaluation which makes it impossible to go forward with the
								exam, the injured worker leaves the evaluation before the completion of the
								evaluation, the injured worker is more than 30 minutes late for the appointment
								and the QME is unable to continue with the scheduled QME appointment, or in the
								case where the appointment has been canceled within six business days of the
								scheduled appointment date. If the physician produces a record review report
								within 30 days of the date of the missed appointment the physician shall be
								reimbursed at the rate of $3.00 per page for any records reviewed in excess of
								200 pages. When billing for a record review report under this code, the
								physician shall include in the report a verification under penalty of perjury
								of the total number of pages of records reviewed by the physician as part of
								the medical-legal evaluation and preparation of the report. Any pages reviewed
								for this record review report will be excluded from the page count for
								reimbursement when the face-to-face or supplemental evaluation takes
								place.
If fees for failed appointments
								and for late cancellations are incurred through the fault or neglect of the
								injured worker or his/her representative, the employer may seek to credit those
								charges against the injured worker's award.
ML201
124
Comprehensive
								Medical-Legal Evaluation.
Includes
($2,015)
all comprehensive
								medical-legal evaluations that do not qualify as follow-up or supplemental
								medical-legal evaluations. The fee includes review of 200 pages of records.
								Review of records in excess of 200 pages shall be reimbursed at the rate of
								$3.00 per page. When billing under this code, the physician shall include in
								the report a verification under penalty of perjury of the total number of pages
								of records reviewed by the physician as part of the medical-legal evaluation
								and preparation of the report.
ML202
81
Follow-up
								Medical-Legal Evaluation.
($1,316.25)
Limited to a
								follow-up medical-legal evaluation by a physician which occurs within eighteen
								months of the date on which a prior comprehensive medical-legal evaluation was
								performed by the same physician. The fee includes review of 200 pages of
								records that were not reviewed as part of the initial comprehensive
								medical-legal evaluation or as part of any intervening supplemental
								medical-legal evaluations. Review of records in excess of 200 pages that were
								not reviewed as part of the initial comprehensive medical-legal evaluation or
								as part of any intervening supplemental medical-legal evaluations shall be
								reimbursed at the rate of $3.00 per page. When billing under this code, the
								physician shall include in the report a verification under penalty of perjury
								of the total number of pages of records reviewed by the physician as part of
								the medical-legal evaluation and preparation of the report.
ML203
40
Fees for
								Supplemental Medical-Legal
($650)
Evaluations.
The fee includes services
								for writing a report after receiving a request for a supplemental report from a
								party to the action or receiving records that were not available at the time of
								the initial or follow-up comprehensive medical-legal evaluation. Fees will not
								be allowed under this section for supplemental reports: (1) following the
								physician's review of information which was available in the physician's office
								for review or was included in the medical record provided to the physician
								prior to preparing a comprehensive medical-legal report or a follow-up
								medical-legal report; or (2) addressing an issue that was requested by a party
								to the action to be addressed in a prior comprehensive medical-legal
								evaluation, a prior follow-up medical-legal evaluation, or a prior supplemental
								medical-legal evaluation. Failure to issue a supplemental report upon request
								because of an inability to bill for the report under this code would constitute
								grounds for discipline by the Administrative Director or his or her designee.
								The fee includes review of 50 pages of records. Review of records in excess of
								50 pages that were received as part of the request for the supplemental report
								shall be reimbursed at the rate of $3.00 per page. When billing under this
								code, the physician shall include in the report a verification under penalty of
								perjury of the total number of pages of records reviewed by the physician as
								part of the supplemental medical-legal evaluation and preparation of the
								report.
ML204
7
Fees for
								Medical-Legal Testimony.
The
($455/hr)
physician shall be
								reimbursed at the rate of RV 7, or his or her usual and customary fee,
								whichever is less, for each quarter hour or portion thereof, rounded to the
								nearest quarter hour, spent by the physician. The physician shall be entitled
								to fees for all itemized reasonable and necessary time spent related to the
								testimony, including reasonable preparation and travel time. The physician
								shall be paid a minimum of two hours for a deposition. If a deposition is
								canceled fewer than eight (8) calendar days before the scheduled deposition
								date, the physician shall be paid a minimum of one hour for the scheduled
								deposition.
ML205
5
Fees for Review of
								Sub Rosa Recordings.
($325/hr)
The physician shall be
								reimbursed at the rate of RV 5, or his or her usual and customary hourly fee,
								whichever is less, for each quarter hour or portion thereof, rounded to the
								nearest quarter hour, spent by the physician for time spent reviewing sub rosa
								recordings. The physician shall include in his or her report verification under
								penalty of perjury of time spent reviewing sub rosa recordings. The fee for
								reviewing sub rosa recordings may be allowed in addition to any fee for any
								single report written by the physician as a result of the review of the sub
								rosa recordings. If the sub rosa recordings are received by a physician prior
								to the issuance of a pending report related to a medical-legal evaluation, the
								physician may not also bill a supplemental report fee in connection with the
								review of the sub rosa material.
ML-PRR
($3.00 per
								page)
Record Review.
This billing code used to
								identify charges for review of records in excess of pages included in
								medical-legal numerical billing codes. Excess pages are billed at three dollars
								per page.
(d) The services described by Procedure Codes
					 ML-201 through ML-203 may be modified under the circumstances described in this
					 subdivision. The modifiers shall not be applicable to per page charges for
					 record review in any of the Procedure Codes ML-201 through ML-203. The
					 modifying circumstances shall be identified by the addition of the appropriate
					 modifier code, which is reported by a two-digit number placed after the usual
					 procedure number separated by a hyphen. The modifiers available are the
					 following:
-92 Performed by a primary treating physician. This
						modifier is added solely for identification purposes, and does not change the
						normal value of the service.
-93 Interpreter needed at time of examination, or other
						circumstances which impair communication between the physician and the injured
						worker and significantly increase the time needed to conduct the examination.
						Requires a description of the circumstance and the increased time required for
						the examination as a result. Where this modifier is applicable, the value for
						the procedure is modified by multiplying the normal value by 1.1. This modifier
						shall only be applicable to ML- 201 and ML-202.
-94 Evaluation performed by an Agreed Medical Evaluator.
						Where this modifier is applicable, the value of the procedure is modified by
						multiplying the normal value by 1.35. If modifier -93 is also applicable for an
						ML-201 or ML-202, then the value of the procedure is modified by multiplying
						the normal value by 1.45.
-95 Evaluation performed by a panel selected Qualified
						Medical Evaluator. This modifier is added solely for identification purposes,
						and does not change the normal value of any procedure.
-96 Evaluation performed by a Psychiatrist or
						Psychologist when a psychiatric or psychological evaluation is the primary
						focus of the medical-legal evaluation. Where this modifier is applicable, the
						value of the procedure is modified by multiplying the normal value by 2. If
						modifier -93 is also applicable for an ML-201 or ML-202, then the value of the
						procedure is modified by multiplying the normal value by 2.10. If modifier -94
						is also applicable for an ML-201 or ML-202, then the value of the procedure is
						modified by multiplying the normal value by 2.35. If both modifier -93 and -94
						are also applicable for an ML-201 or ML-202, then the value of the procedure is
						modified by multiplying the normal value by 2.45.
-97 Evaluation performed by a physician who is board
						certified in Toxicology, a physician who is certified as a Qualified Medical
						Evaluator in the specialty of Internal Medicine or a physician who is board
						certified in Internal Medicine, when a Toxicology evaluation is the primary
						focus of the medical-legal evaluation. Where this modifier is applicable, the
						value of the procedure is modified by multiplying the normal value by 1.50. If
						modifier -93 is also applicable for an ML-201 or ML-202, then the value of the
						procedure is modified by multiplying the normal value by 1.60. If modifier -94
						is also applicable for an ML-201 or ML-202, then the value of the procedure is
						modified by multiplying the normal value by 1.85. If both modifier -93 and -94
						are also applicable for an ML-201 or ML-202, then the value of the procedure is
						modified by multiplying the normal value by 1.95.
-98 Evaluation performed by a physician who is board
						certified in Medical Oncology, a physician who is certified as a Qualified
						Medical Evaluator in the specialty of Internal Medicine or a physician who is
						board certified in Internal Medicine, when an Oncology evaluation is the
						primary focus of the medical-legal evaluation. Where this modifier is
						applicable, the value of the procedure is modified by multiplying the normal
						value by 1.50. If modifier -93 is also applicable for an ML-201 or ML-202, then
						the value of the procedure is modified by multiplying the normal value by 1.60.
						If modifier -94 is also applicable for an ML-201 or ML-202, then the value of
						the procedure is modified by multiplying the normal value by 1.85. If both
						modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the
						value of the procedure is modified by multiplying the normal value by
						1.95.
(e) Requests for
					 duplicate reports shall be in writing. Duplicate reports shall be separately
					 reimbursable and shall be reimbursed in the same manner as set forth in the
					 Official Medical Fee Schedule adopted pursuant to Labor Code Section
					 5307.1.
(f) This section shall be effective as of
					 April 1, 2021 and shall apply to the following:
(1) medical-legal evaluation reports where
					 the examination occurs on or after April 1, 2021;
(2) medical-legal testimony provided on or
					 after April 1, 2021; and
(3)
					 supplemental medical legal reports that are requested on or after April 1, 2021
					 regardless of the date of the original examination.