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.
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.
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:
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 |
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 |
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.