To help demystify California Medical-Legal record review billing code MLPRR, daisyBill published an MLPRR guide for California physician evaluators.
Our inbox promptly overflowed with requests for clarification on how to report MLPRR compliantly when page counts climb to mind-numbingly high counts — specifically, when the page count exceeds the capacity of a single line item on the universal CMS-1500 billing form.
Between April 1, 2021 and February 11, 2022, daisyBill providers submitted 89,791 Medical-Legal bills using the CMS 1500 form, 32 of which listed 10,000+ pages/units of MLPRR. For these 32 bills, cumulatively the evaluators were reimbursed a total of $960,222.
Below, we explain how to bill for 10,000 (or more) pages of MLPRR when submitting a CMS-1500 billing form for a Medical-Legal evaluation or report with excessive record review.
A. To bill for the pages reviewed, the physician must report the total page count as the total units for MLPRR. For each page/unit of records reviewed, as reported by MLPRR, the MLFS reimbursement is $3. For detailed billing instructions: MLPRR: Record Review Guide for CA Med-Legal MDs
A: daisyBill recommends submitting Medical-Legal bills using the CMS-1500 form.
The Division of Workers’ Compensation (DWC) has never implemented bill submission requirements for Medical-Legal billing. Crumpled up post-it note? Perfectly acceptable. Carrier pigeon? Cool! Just check the forecast first.
BUT, for consistency’s sake, we recommend physicians submit Medical-Legal bills electronically* on the CMS-1500 form, and list the number of units of MLPRR in Box 24, Section G.
*Note that California law does not require claims administrators to accept electronic bills for Medical-Legal services. If necessary, send a non-electronic paper CMS-1500.
A: It depends. The instructions are different depending on whether you are submitting the CMS-1500 electronically or via paper. For a paper CMS-1500, page 41 of the National Uniform Claim Committee (NUCC) 1500 Health Insurance Claim Form Reference Instruction Manual states that for each line on the CMS-1500 form only 3 digits may be entered in Box 24, Section G as the count of units.
However, when bills are transmitted electronically (instead of on paper), providers can bill for up to 9,999 units of MLPRR as a single line item.
A: Enter 9999 next to procedure code MLPRR on one line. Then, add a second line item to account for the remaining units of MLPRR (see example below).
Since the Medical-Legal bill was transmitted electronically, the units for MLPRR must reflect 9,999 + 4,976 = 14,975 (As a reminder, the electronic transmission can accommodate the large 4-digit counts of MLPRR units).
A: As noted above, when the CMS-1500 is transmitted on the paper form via the mail, the paper CMS-1500 form can only accommodate 3 digits of units. For the same example from above, to submit a paper CMS-1500, the 14,795 pages of records would require 15 separate MLPRR entries. Further, the paper CMS-1500 form only accommodates 6 entries. Accordingly, to report 14,795 pages of records reviewed, the provider would need to submit 3 pages of the CMS-1500 form as shown below.
A: Yes. daisyBill is here to help.
We’ve compiled many FREE resources to help ALL physicians (not just our clients) cut through the confusion caused by unclear DWC directions.
Our most recent Medical-Legal Billing Webinar explains the nuances of the new MLFS, and is accessible on demand. Alternatively, feel free to email us with your questions (contact form link below).
DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.