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Medical-Legal Cheat Sheet: Reimbursements

January 24, 2018 by Catherine Montgomery

Billing for medical-legal services is one of the trickiest aspects of workers’ comp revenue management. Further complicating the process is the time-based nature of many medical-legal billing codes, with providers and insurance claims administrators disputing which codes are billable by time, and what constitutes a single unit of time.

Here, we offer a guide on compliant medical-legal billing, for your easy reference.

Which Medical-Legal Billing Codes are Time-Based?

This one’s fairly straightforward, but there is a twist.

Of the seven medical-legal billing codes (ML100 - ML106), four of them are time-based. For these four codes, providers bill in units of time, with final reimbursement dependent on how long the service took to provide.

The remaining three, ML100 for missed appointments, ML102 for Basic Comprehensive Medical-Legal Evaluations, and ML103 for Complex Comprehensive Medical-Legal Evaluations apply to flat service-based fees. For these codes, time is not a factor. The basic or comprehensive evaluation (or missed appointment) has a set price, regardless of how long it takes — with one exception.

Medical-Legal Reimbursements

For the four time-based medical-legal billing codes, the time for which providers bill is measured in units. For all time-based codes, one unit = 15 minutes. For example, for a service that takes 45 minutes, the provider bills 3 units’ worth of the appropriate billing code.

At DaisyBill, we’ve heard complaints alleging that some claims administrators insist on 1 hour billing units. This is incorrect.

The Medical-Legal Fee Schedule reimbursement rate per unit is the same for all four time-based codes, $62.50. Two billing code modifiers may apply to these billing codes. Modifier 94 for Agreed Medical Evaluator (AME) services raises the reimbursement. Modifier 95 for panel-selected Qualified Medical Evaluator (QME) services does not affect reimbursement, but identifies the provider’s role as the panel QME.

To easily identify the appropriate reimbursement for medical-legal services, refer to the following guides:

Medical-Legal Reimbursements, Non-Time-Based

Billing Code

Procedure

Modifier(s)

Reimbursement

ML100

Missed Appointment

N/A

By Report

ML102

Basic Comprehensive Medical-Legal Evaluation

None

$625.00

ML102

Basic Comprehensive Medical-Legal Evaluation

93 (With Interpreter)

$687.50

ML102

Basic Comprehensive Medical-Legal Evaluation

94 (AME)

$781.25

ML 102

Basic Comprehensive Medical-Legal Evaluation

95 (Panel QME)

$625.00

ML 102

Basic Comprehensive Medical-Legal Evaluation

93 (With Interpreter) + 94 (AME)

$843.75

ML 102

Basic Comprehensive Medical-Legal Evaluation

93 (With Interpreter) + 95 (Panel QME)

$687.50

ML 103

Complex Comprehensive Medical-Legal Evaluation

None

$937.50

ML 103

Complex Comprehensive Medical-Legal Evaluation

93 (With Interpreter)

$1,031.25

ML 103

Complex Comprehensive Medical-Legal Evaluation

94 (AME)

$1,171.88

ML 103

Complex Comprehensive Medical-Legal Evaluation

95 (Panel QME)

$937.50

ML 103

Complex Comprehensive Medical-Legal Evaluation

93 (With Interpreter) + 94 (AME)

$1,265.63

ML 103

Complex Comprehensive Medical-Legal Evaluation

93 (With Interpreter) + 95 (Panel QME)

$1,031.25

Medical-Legal Reimbursements, Time Based (ML101, ML104, ML105, ML106)

Time in Minutes

Units

No Modifier

Modifier 94 (AME)

Modifier 95 (Panel QME)

15

1

$62.50

$78.13

$62.50

30

2

$125.00

$156.26

$125.00

45

3

$187.50

$234.39

$187.50

60

4

$250.00

$312.52

$250.00

75

5

$312.50

$390.65

$312.50

90

6

$375.00

$468.78

$375.00

105

7

$437.50

$546.91

$437.50

120

8

$500.00

$625.04

$500.00

135

9

$562.50

$703.17

$562.50

150

10

$625.00

$781.30

$625.00

165

11

$687.50

$859.43

$687.50

180

12

$750.00

$937.56

$750.00

195

13

$812.50

$1015.69

$812.50

210

14

$875.00

$1093.82

$875.00

225

15

$937.50

$1171.95

$937.50

240

16

$1000.00

$1250.08

$1,000.00

255

17

$1062.50

$1328.21

$1,062.50

270

18

$1125.00

$1406.34

$1,125.00

285

19

$1187.50

$1484.47

$1,187.50

300

20

$1250.00

$1562.60

$1,250.00

315

21

$1312.50

$1640.73

$1,312.50

330

22

$1375.00

$1718.86

$1,375.00

We’ll update our readers of any changes to the official reimbursements according to the Medical-Legal Fee Schedule. For more detailed information on the compliant application of Modifier 93, see the following blog posts:

Modifier 93 for Examinations Requiring Interpreter Services: A DaisyBill Guide

Stay Compliant: An Update on Modifier 93 for Exams Requiring Interpreter Services

Providers may apply Modifier 93 to codes ML102 and ML103 only, to reflect the extra time necessitated by interpreter services. While no specific units of time apply to Modifier 93, it specifically addresses the fact that evaluations with an interpreter take longer.

To determine if a billing code is time-based or not, and whether Modifier 93 may be applied, use this chart:

Billing Code

Procedure

Time-Based?

Modifier 93 Applicable?

ML100

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

NO

NO

ML101

Follow-up Medical-Legal Evaluation

YES

NO

ML102

Basic Comprehensive Medical-Legal Evaluation

NO

YES

ML103

Complex Comprehensive Medical-Legal Evaluation

NO

YES

ML104

Comprehensive Medical-legal Evaluation Involving Extraordinary Circumstances

YES

NO

ML105

Fees for medical-legal testimony

YES

NO

ML106

Fees for supplemental medical-legal evaluations

YES

NO

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DaisyBill offers a full suite of cloud-based billing software to help providers easily obtain the correct reimbursement. Schedule a free demonstration today, and see how DaisyBill can improve your bottom line.

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