Medical-Legal Fee Schedule: DWC Proposes New Amendments

Medical-Legal Fee Schedule: DWC Proposes New Amendments

The California Division of Workers’ Compensation (DWC) announced proposed amendments to the Medical-Legal Fee Schedule yesterday, May 3.

The amendments would make significant changes to medical-legal billing practices. These changes include new limits on billing under the Official Medical Fee Schedule (OMFS), and new rules for the application of the ever-troublesome complexity factors for codes ML103 and ML104.

The DWC will accept public comments until 5 pm on Friday, May 18. DaisyBill will host a free medical-legal billing webinar on May 10.

Download DaisyBill's Free Medical-Legal Fee Schedule Webinar

Newsline 2018-35 announced the proposals, available in full on the DWC’s public forum. Among the most impactful changes are:

  • An addition to California Code of Regulations (CCR) Section 9794(a) that would limit when medical-legal doctors may bill under the OMFS.  Medical-legal doctors will have permission to bill under the OMFS for x-rays, laboratory services, and other diagnostic tests only.

    See our previous blog on
    medical-legal diagnostic testing for further information.
  • An addition to CCR § 9795(d) that bars medical-legal doctors from requiring prior agreement of the parties that would justify the use of a given billing code (eg, agreement that “extraordinary circumstances” are present to qualify an examination for code ML104). While such agreements are not barred, such agreements cannot be a condition of conducting the evaluation.
  • A three hour limit to billable time spent in report preparation under codes ML101, ML106, and in certain circumstances under ML104.
  • Stricter standards for justifying the use of code ML103, including clarification of how medical-legal doctors may and may not combine complexity factors.
  • Acknowledgement that report preparation is always billable under ML104.
  • New limits on billing for medical research under ML103, ML104, and ML106.

    The medical-legal doctor may only bill for medical research using sources the doctor has
    not cited in any prior medical report in support of the complexity factor in question over the preceding year. Documentation of the research and its necessity is far more stringent as well.

We'll discuss the changes in more detail, as well as any further updates, here on our blog.

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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