Recently, a DaisyBill client faced unreasonable demands from a bill review regarding complexity factors for medical-legal billing code ML104. Fortunately, our client’s refusal to accept arbitrary requirements ultimately won out — proof that providers can succeed when empowered with knowledge of the rules.

Substantiating Complexity Factors

The provider in question billed for a Comprehensive Medical-Legal Evaluation Involving Extraordinary Circumstances, using code ML104. The claims administrator’s bill review, however, insisted on an unheard-of level of documentation to validate the application of this billing code.

To qualify for ML104, an evaluation must involve a certain number of “complexity factors.”

California Code of Regulations (CCR) Section 9795 describes the qualifying complexity factors under code ML103 for Complex Comprehensive Medical-Legal Evaluations. Complexity factors include:

1. Two or more hours of face-to-face time with the injured worker
2. Two or more hours of record review
3. Two or more hours of medical research
4. Four or more hours spent on a combination of any two of complexity factors 1 through 3.
5. Six or more hours spent on a combination of all three complexity factors 1 through 3
6. Addressing medical causation
7. Addressing apportionment, under certain specific circumstances
8. A primarily psychiatric or psychological evaluation

To qualify for ML104, an evaluation must include:

1. Four or more complexity factors (as described under ML103)
   
   OR
   
2. Multiple prior injuries to the body part being evaluated AND three or more complexity factors (including 3 or more hours of record review)
   
   OR
   
3. Agreement by the parties that the evaluation involves extraordinary circumstances

Note: the recent lawsuit, as well as the language for proposed amendments to ML104, resolved a long-simmering debate about the role of report preparation in billing with code ML104. See our previous post for details, but remember that report preparation is not a complexity factor.

In our client’s case, the first complexity factor — extended face-to-face time with the injured worker — was the source of the dispute with the bill review.

Making Up The Rules?

The bill review insisted the provider exceed CCR § 9795’s requirements for substantiating face-to-face time with the injured worker. As the regulation states, to justify application of ML104, providers must:

...clearly and concisely specify which four or more of the complexity factors were required for the evaluation, and the circumstances which made these complexity factors applicable to the evaluation.

With the exception of complexity factor 3 (medical research), no further requirements exist for substantiating the complexity factors.

The bill review, however, thought otherwise. They insisted the provider document the exact times between which the provider was face-to-face with the injured worker, eg from 10:23 am to 1:17 pm, to validate billing for the first complexity factor.

Our client suspected this requirement was not within a bill review or claims administrator’s right to enforce. The provider contacted DaisyBill, asking if any regulations supported the bill review’s requirement.

Of course, no regulations whatsoever supported such a rule.

Neither bill review nor the claims administrator may impose such a baseless and arbitrary chore on providers. Workers’ comp billing (and medical-legal billing, in particular) are burdensome enough in their requirements. We advised the provider to refuse such impositions, even to refuse to conduct evaluations for the claims administrator in question.

Insist on Compliance

As it turned out, our client’s dogged refusal was rewarded.

After our conversation, the provider challenged the bill review’s Clinical Validation Team to support their rule with language from the regulations. After coming up empty, the bill review relented, agreeing to pay the disputed medical-legal bill in full.

Bill review also expressed their intention to send a company-wide memo reversing their position on substantiating face-to-face time with exact times.

Providers, this is what happens when you know the rules, and accept nothing less than full compliance from payors. Understanding the workers’ comp billing and payment system (however convoluted) is the best way to protect your office’s revenue.

DaisyBill offers everything medical-legal providers need to navigate the complex labyrinth of medical-legal billing rules and ensure correct, timely payment. Schedule a free demonstration of DaisyBill’s Billing Software today, and see what we can do for your practice.

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