2021 Med-Legal Fee Schedule Changes -- Join us for a free webinar on April 15 at 1pm PDT
2021 Medical-Legal Cheat Sheet for CA Workers' Comp

2021 Medical-Legal Cheat Sheet for CA Workers' Comp

It’s official: California workers’ compensation has a new Medical-Legal Fee Schedule (MLFS).

Substantially different from its predecessor, the updated MLFS is effective for dates of service on or after April 1, 2021. DaisyBill will host a webinar to explore the new rules in detail. In the meantime, below is a Medical-Legal “Cheat Sheet” featuring key reimbursement information and billing rules.

Refer to this when billing for Medical-Legal services, and sign up for our webinar here.

Medical-Legal Billing Codes Effective April 1

Below are the new Medical-Legal billing codes, with descriptions for the Medical-Legal services each code represents, and the accompanying reimbursement amounts. The new billing rules and reimbursements are effective for:

  • All Medical-Legal evaluations that occur on or after April 1, 2021
  • Medical-Legal testimony provided on or after April 1, 2021
  • Supplemental Medical-Legal reports requested on or after April 1, 2021, regardless of the date of the initial Medical-Legal examination

Billing Code

Service/Description

Reimbursement

ML200

Missed Appointment: Missed appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation

$503.75

ML201

Comprehensive Medical-Legal Evaluation: All comprehensive medical-legal evaluations that do not qualify as follow-up or supplemental medical-legal evaluations

$2,015

ML202

Follow-up Medical-Legal Evaluation: 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

$1,316.25

ML203

Supplemental Medical-Legal Evaluation: 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

$650.00

ML204

Medical-Legal Testimony (Time-Based): All itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time

$113.75 for each 15-minute increment

ML205

Sub Rosa Recording Review (Time-Based): Time spent reviewing sub rosa recordings

$81.25 for each 15-minute increment

MLPRR

Record Review: Used to identify charges for review of records in excess of pages included in medical-legal numerical billing codes

$3.00 per page*

*See important information regarding record review under “Record Review Requirements” below.

Important Qualifications

Refer to the table below for important details regarding the application of each Medical-Legal billing code.

Billing Code

Application Details

ML200

Missed Appointment - Includes instances where:

  • The injured worker does not show up for the evaluation
  • The interpreter does not show up for the evaluation, precluding the evaluation
  • 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
  • The appointment is canceled within six business days of the scheduled appointment date

ML201

Comprehensive Medical-Legal Evaluation - Includes all comprehensive medical-legal evaluations that do not qualify as either:

  • Follow-up Medical-Legal evaluations, or
  • Supplemental Medical-Legal evaluations

ML202

Follow-up Medical-Legal Evaluation - Must be performed by a Qualified Medical Evaluator (QME), Agreed Medical Evaluator (AME), or the Primary Treating Physician (PTP) within 18 months following the evaluator's examination of the employee in a comprehensive Medical-Legal evaluation

ML203

Supplemental Medical-Legal Evaluation - Fees are not allowed for supplemental reports:

  • Following the physician's review of information which was available in the physician's office for review, or which 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
  • Addressing an issue that a party to the action requested be addressed in a prior comprehensive Medical-Legal evaluation, follow-up Medical-Legal evaluation, or supplemental Medical-Legal evaluation

ML204

Medical-Legal Testimony - For each quarter hour (rounded to the nearest quarter hour spent by the physician), the physician is reimbursed at the rate of $455/hour or his or her usual and customary fee, whichever is less.

The physician shall be paid a minimum of two hours for a deposition.

If a deposition is canceled fewer than 8 calendar days before the scheduled deposition date, the physician shall be paid a minimum of one hour for the scheduled deposition.

ML205

Sub Rosa Recording Review - For each quarter hour (rounded to the nearest quarter hour spent by the physician), the physician is reimbursed at the rate of $325/hour or his or her usual and customary hourly fee, whichever is less.

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.

MLPRR

Record Review - “Record Review” means review by a physician of documents sent to the physician in connection with a medical-legal evaluation or request for report. The documents may consist of medical records, legal transcripts, medical test results, and/or other relevant documents.

Record Review Requirements

Record review under the new MLFS must conform to the following requirements in order to be compensable:

  • The record review must be conducted by a physician.
  • “Records” refers to documents sent to the physician in connection with a Medical-Legal evaluation or request for report.
  • The documents may consist of medical records, legal transcripts, medical test results, and/or other relevant documents.
  • Any documents sent to the physician for record review must be accompanied by a declaration (under penalty of perjury) that the person or entity providing the documents has complied with the provisions of Labor Code section 4062.3.
  • The declaration regarding LAB § 4062.3 must contain an attestation as to the total page count of the documents provided.
  • A physician may not bill for review of documents that are not accompanied by the LAB § 4062.3 declaration. Any documents missing the required declaration and page count attestation are invalid for the purposes of record review or any other physician duty regarding records and report writing.

Below are the requirements for applying per-page record review billing code MLPRR, in conjunction with other Medical-Legal billing codes. When applying MLPRR, consider the following:

  • Reimbursements for billing codes ML200, ML201, and ML202 include 200 pages of record review. If the evaluation requires further record review, the physician may apply MLPRR for additional pages. For ML203, the threshold is 50 pages of record review before the physician may apply MLPRR.
  • The new MLFS defines a “page” as “an 8 ½ by 11 single-sided document, chart or paper, whether in physical or electronic form. Multiple condensed pages or documents displayed on a single page are charged as separate pages.”
  • When billing for record review, the provider must include in the report a verification of the total number of pages reviewed, under penalty of perjury.
  • Modifier increased reimbursements are not applicable to any per page charges for record review.

ML Code

MLPRR Requirements

ML200

Bill one unit of MLPRR for each page of records reviewed in excess of 200 pages, when the physician produces a record review report within 30 days of the date of the missed appointment

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.

ML201

Bill one unit of MLPRR  for each page of records reviewed in excess of 200 pages.

ML202

Bill one unit of MLPRR  for each page of records reviewed in excess of 200 pages.

The fee includes review of 200 pages of records that were not reviewed as part of:

  • The initial comprehensive medical-legal evaluation, or
  • Any intervening supplemental medical-legal evaluations.

ML203

Bill one unit of MLPRR  for each page of records reviewed in excess of 50 pages. Records must be received as part of the request for the supplemental report.

ML204

N/A: Time-Based

ML205

N/A: Time-Based

New Modifier Rules

The new MLFS reworks the application of billing code modifiers -92 through -95, and adds modifiers -96, -97, and -98. Physicians may apply modifiers to codes ML201, ML202, and ML203.

Again, modifiers are not applicable to MLPRR for per-page record review.

Modifier

Application

-92

The evaluation was performed by a primary treating physician (PTP). Modifier -92 is strictly for identification purposes and does not alter reimbursement.

-93

The evaluation required an interpreter, or other circumstances so impaired communication between patient and physician as to significantly increase the time necessary to conduct the evaluation.

This modifier requires a description of the circumstances and the increased time required as a result. Use - 93 to modify reimbursement by multiplying the normal reimbursement by 1.1.

-93 is applicable only to ML201 and ML202

-94

The evaluation was performed by an Agreed Medical Evaluation (AME).

Use -94 to modify reimbursement by multiplying the normal reimbursement by 1.35. For ML201 or ML202, when modifier -93 is also applicable, multiply the normal reimbursement by 1.45.

-95

The evaluation was performed by a panel-selected Qualified Medical Evaluator (QME). Modifier -95 is strictly for identification purposes and does not alter reimbursement.

-96

The evaluation was:

  • Performed by a psychiatrist or psychologist, when
  • A psychiatric or psychological evaluation is the primary focus of the evaluation

Use -96 to modify reimbursement by multiplying the normal reimbursement by 2. For ML201 or ML202:

  • When modifier -93 is also applicable, multiply normal reimbursement by 2.1
  • When modifier -94 is also applicable, multiply normal reimbursement by 2.35
  • When modifiers -93 and -94 are also applicable, multiply normal reimbursement by 2.45

-97

A toxicology evaluation was the primary focus of the evaluation, and the evaluation was performed by a physician who is:

  • Board certified in Toxicology, or
  • Certified as a QME in the specialty of Internal Medicine, or
  • Board certified in Internal Medicine

Use -97 to modify reimbursement by multiplying the normal reimbursement by 1.5. For ML201 or ML202:

  • When modifier -93 is also applicable, multiply normal reimbursement by 1.6
  • When modifier -94 is also applicable, multiply normal reimbursement by 1.85
  • When modifiers -93 and -94 are also applicable, multiply normal reimbursement by 1.95

-98

An oncology evaluation was the primary focus of the evaluation, and the evaluation was performed by a physician who is:

  • Board certified in Medical Oncology, or
  • Certified as a QME in the specialty of Internal Medicine
  • Board certified in Internal Medicine

Use modifier -98 to modify reimbursement by multiplying the normal reimbursement by 1.5. For ML201 or ML202:

  • When modifier -93 is also applicable, multiply normal reimbursement by 1.6
  • When modifier -94 is also applicable, multiply normal reimbursement by 1.85
  • When modifiers -93 and -94 are also applicable, multiply normal reimbursement by 1.95

DaisyBill’s comprehensive 2021 Medical-Legal Billing webinar will take place on April 14 at 1 PM Pacific time. We expect a large turnout, so secure your seat by signing up below. As always, feel free to submit any questions about the new MLFS when you register:

SAVE MY SEAT: 2021 MLFS


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