Millions of pages. Millions of dollars. Potentially serious consequences for non-compliance.

Medical-Legal record review can be a big challenge for physician evaluators — and we’re here to help.

To help ensure compliance (and accurate reimbursement) for record review under Medical-Legal billing code MLPRR, refer to the guide and checklist below.*

MLPRR 101

On April 1, 2021, the newly revamped Medical-Legal Fee Schedule (MLFS) took effect in California. Included in the new MLFS is a per-page record review billing code, MLPRR.

The base numerical billing codes for Medical-Legal evaluations (and missed appointments) include reimbursement for a limited amount of record review. For example, the $2,015 reimbursement for ML201 (for a Comprehensive Evaluation) covers reimbursement for up to 200 pages of record review.

The MLPRR billing code allows the physician to bill for pages of records reviewed in excess of the base numerical codes’ page limits.

To continue with the ML201 example, if the physician reviews 200 or fewer pages, MLPRR does not apply. But from page 201 on, the physician may bill 1 unit of MLPRR for each page, at $3 per unit.

Needless to say, those excess pages add up, representing millions of dollars in revenue.

When to Use MLPRR

Physicians may only bill MLPRR in conjunction with one of the 4 base numerical billing codes to which record review applies, as follows:

What Counts as “Records?”

California Code of Regulations (CCR) Section 9793 defines “record review” for the purpose of Medical-Legal evaluations. According to CCR §9793(n), “Record Review” is “the review by a physician of documents sent to the physician in connection with a Medical-Legal evaluation or request for report.” [emphasis added]

Such documents may include:

• Medical records
• Legal transcripts
• Medical test results
• ”...other relevant documents”

As physicians may bill for record review (in excess of the base numerical code’s limit) by page, §9793 defines a single “page” as:

• Single-sided
• 8 ½ by 11 inch
• In “physical or electronic form”

Further, physicians may bill for “multiple condensed pages or documents displayed on a single page” separately. If the sender of records shrinks two 8 ½ by 11 inch pages and copies them onto a single page, that’s still 2 pages. If an 8 ½ by 11 inch page includes information on the front and back, that’s also 2 pages.

Finally, MLPRR places no cap on the number of pages physicians may review and bill for. If the parties send an 18-wheeler load of allowable documents (with the proper declaration and attestation described below), review and bill accordingly. For example, see the high page counts and payments from actual Explanations of Review (EOR) below:

Record Sender: Declaration and Attestation Requirements

The new MLFS requires both the sender of records (i.e. the attorneys) and the physician to document exactly how many pages are sent and reviewed, respectively, for each evaluation.

When sending records to a Medical-Legal evaluator, regulations require the sender to include a declaration, signed under penalty of perjury, that includes two required statements:

• A statement that the sender, prior to sending the records, complied with Labor Code section 4062.3 (which outlines certain protocols regarding the sending of records)
• An attestation of the exact number of pages of medical records the physician is asked to review

Evaluator: Verification Requirements

The new MLFS mandates that the physician evaluator must include verification of the exact number of pages reviewed in the evaluation report, also under penalty of perjury. See examples below.

Missing or Faulty Declaration & Attestation

If the sender of records fails to include an accurate declaration of the number of pages, the physician evaluator may not:

• Consider the content of those records when preparing the evaluation report
• Bill for review of those records

In other words, if the required declaration and page count attestation is not present, or not accurate, do not review those records.

Not only is the physician barred from billing for records sans declaration/attestation; the physician may not consider the contents of such records in their evaluation. According to CCR §9793:

A physician may not bill for review of documents that are not provided with this accompanying required declaration from the document provider.

Any documents or records that are sent to the physician without the required declaration and attestation shall not be considered available to the physician or received by the physician for purposes of any regulatory or statutory duty of the physician regarding records and report writing. [emphasis added]

The physician may still conduct the Medical-Legal evaluation and issue a report, irrespective of the improperly sent records. However, we recommend documenting faulty or missing declarations/attestations in the evaluation report, using the same table format as above.

MLPRR Checklist

Before submitting a bill for a Medical-Legal evaluation that includes charges for MLPRR, physicians should ensure the following:

• The base numerical billing code allows MLPRR (ML200, ML201, ML202, ML203)
• The number of pages sent by the parties exceeds the base numerical code’s medical record page limit
• The physician personally reviewed the records
• The records sent include a Declaration of compliance with Labor Code §4062.3
• The records sent include an accurate attestation of the total number of pages for review
• The evaluation report includes an accurate verification of the total number of pages reviewed by the physician evaluator

Medical-Legal record review billing warrants extra time and care to conduct properly. For further help, see our recent Medical-Legal billing webinar, or reach out for a chat.

*Disclaimer: the information in this post is strictly for informational purposes. It is not legal advice; use at your own risk and discretion.

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