Although California’s updated Medical-Legal Fee Schedule has been in effect for a little over a year now, an overview is always helpful. In this quick guide, you’ll find California’s med-legal billing codes, along with their modifiers and some crucial information about each code.
I – Med-Legal Billing Codes in California
ML200 Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation
- The injured worker does not show up for the evaluation.
- The interpreter does not show up for the evaluation.
- The injured worker leaves the evaluation before its completion.
- The injured worker is more than 30 minutes late for the appointment and the QME is unable to continue with the scheduled QME appointment.
- The appointment has been canceled within six business days of the scheduled appointment date.
Reimbursement: $503.75
ML201 Comprehensive Medical-Legal Evaluation
- For all comprehensive medical- legal evaluations that do not qualify as follow-up or supplemental medical- legal evaluations.
Reimbursement: $2,015
ML202 Follow-up Medical-Legal Evaluation
- The use of this code is limited to a follow-up medical-legal evaluation by a physician which takes place within eighteen months of the date on which a prior comprehensive medical-legal evaluation was performed by the same physician.
Reimbursement: $1,316.25
ML203 Fees for Supplemental Medical-Legal Evaluations
- Use this code for services for writing a report after receiving a request for a supplemental report from a party to the action or receiving records that were not available at the time of the initial or follow-up comprehensive medical-legal evaluation.
Reimbursement: $650
ML204 Fees for Medical-Legal Testimony
- Keep in mind: The physician shall be entitled to fees for all itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time. The physician shall be paid a minimum of two hours for a deposition.
Reimbursement: $455/hr
ML-PRR Fees for Review of Sub Rosa Recordings
- Review of sub rosa recordings by a physician.
Reimbursement: $325/hr ($113.75/quarter hr)
II – Modifiers to Codes ML-201 through ML-203
Procedure Codes ML-201 through ML-203 may be modified under certain circumstances using the modifiers listed below
Modifier -92
Performed by a primary treating physician. This modifier is added solely for identification purposes; it does not change the normal value of the service.
Modifier -93
Interpreter needed at time of examination, or other circumstances which impair communication between the physician and the injured worker and significantly increase the time needed to conduct the examination.
- Where this modifier is applicable, the value for the procedure is modified by multiplying the normal value by 1.1.
- Only applicable to ML-201 and ML-202
Modifier -94
Evaluation performed by an Agreed Medical Evaluator.
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.35.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.45.
Modifier -95
Evaluation performed by a panel selected Qualified Medical Evaluator. This modifier is added solely for identification purposes; it does not change the normal value of the procedure.
Modifier -96
Evaluation performed by a Psychiatrist or Psychologist when a psychiatric or psychological evaluation is the primary focus of the medical-legal evaluation.
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 2.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.10.
- If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.35.
- If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.45.
Modifier -97
Evaluation performed by a physician who is board certified in Toxicology, a physician who is certified as a Qualified Medical Evaluator in the specialty of Internal Medicine or a physician who is board certified in Internal Medicine, when a Toxicology evaluation is the primary focus of the medical-legal evaluation.
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.50.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.60.
- If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.85.
- If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.95.
Modifier -98
Evaluation performed by a physician who is board certified in Medical Oncology, a physician who is certified as a Qualified Medical Evaluator in the specialty of Internal Medicine or a physician who is board certified in Internal Medicine, when an Oncology evaluation is the primary focus of the medical-legal evaluation.
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.50.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.60.
- If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.85.
- If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.95.
Practice IQ: Med Legal Billing in California
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