California Medical Bill Reviewer Re-Certification

California Medical Bill Reviewer Re-Certification Unit 3: Medical Legal Fee Schedule Module 1: Medical Legal Services Guidelines

Lastly, you will learn about the different med legal codes, as well as modifiers that can be used when billing for these services. You will learn about contested claims, disputed medical facts, and how med legal evaluations help to prove or disprove disputed medical facts. Hi! In this module, you will learn about medical legal services, the circumstances under which they are required, and how they are reimbursed. Let’s start by discussing some general med legal guidelines... Overview • Medical Legal Services • Medical Legal Services • Medical Legal Evaluations • Contested Claims • Disputed Medical Facts • Medical Legal Codes & Complexity Factors • Modifiers

Up until this point, you have learned about different sections of the Official Medical Fee Schedule. Medical legal services are necessary when an aspect of an injury claim, a patient’s injury, or a patient’s diagnosis is contested. Medical Legal Fee Schedule In contrast to these sections, Medical Legal Services are covered in a separate fee schedule.

A medical legal evaluation is an evaluation of an employee to prove or disprove a contested claim. Medical Legal Evaluations • Following a medical legal evaluation, a physician prepares a report which substantiates or disproves a disputed medical fact. Medical legal evaluations are performed by: • Qualified medical examiners • Agreed medical evaluators • Primary treating physicians • You might not be familiar with the difference between a QME and an AME. Let’s take a look...

Medical Legal Evaluations Qualified Medical Examiner (QME) A qualified medical examiner is an independent physician who is certified to perform medical evaluations. Agreed Medical Evaluator (AME) An agreed medical evaluator is a physician appointed by attorneys and the claims administrator to perform a med legal evaluation and submit a report of his/her findings. Primary Treating Physician (PTP) You might recall that the primary treating physician is the physician responsible for overseeing the total care of an injured worker. Now let’s take a look at the circumstances in which a medical legal evaluation may be necessary.

Medical Legal Evaluations • Two concepts important to your understanding of medical legal evaluations are: Contested Claims Disputed Medical Facts Let’s take a look…

Contested Claims • Contested claims can occur under different circumstances. Circumstance 1 A claim for which a claims administrator rejects liability. A claim for which a claims administrator has failed to accept liability. Circumstance 2 Circumstance 3 A claim for which a claims administrator has failed to respond to a demand for payment of indemnity benefits. Circumstance 4 A claim for which a claims administrator accepts liability for the claim, but a disputed medical fact exists.

Disputed Medical Facts • A disputed medical fact is an issue in dispute, such as an objection to a medical determination made by a treating physician. • Contested claims may arise from disputed medical facts. The dispute may concern: • An employee’s medical condition. • The cause of the medical condition. • The treatment for the medical condition. • The existence, nature, duration, or extent of disability caused by employee’s medical condition. • The medical eligibility for rehabilitation services.

Medical Legal Codes Just like other types of service, med-legal services have a specific set of codes by which reimbursement is determined. Let’s take a look…

Much like other types of codes, such as procedure codes, medical legal (ML) codes each have an associated relative value. Reimbursement for a medical legal evaluation is calculated by multiplying the relative value associated with a specific code by $12.50, and adding any additional reimbursement due to modifiers. Medical Legal Codes RV x $12.50 + Applicable Modifiers =Med Legal Reimbursement

Medical Legal Codes • Reimbursement for medical legal services accounts for many different aspects of service. Fees include reimbursement for: • History and physical examination. • Review of records. • Preparation of the report, including typing and transcription services. • Overhead expenses. • Med legal codes correspond to different levels of evaluation, med legal testimony, and even missed appointments. Let’s take a look…

ML 100 indicates a missed appointment for a comprehensive or follow-up med legal evaluation. ML 100 Therefore, reimbursement is at the discretion of the claims administrator. This code does notnecessitate payment. What might this mean? This code is informational only.

ML 101 • ML 101 is used to indicate a follow-up medical legal evaluation. ML 101: Follow-up Med Legal Evaluation RV: 5 • The follow-up evaluation must occur within nine months of the provider’s initial evaluation. • The physician must specify the amount of time spent reviewing records, face-to-face time, and time preparing the report. • Time spent shall be tabulated in increments of 15 minutes, or portions thereof, rounded to the nearest quarter hour.

ML 102 • ML102 is used when a basic comprehensive medical legal evaluation is performed. ML 102: Basic Comprehensive Med Legal Evaluation RV: 50 • This code includes all comprehensive med-legal evaluations other than the evaluations subject to ML 103 and 104. If a provider billed ML 102, what would the total reimbursement be? Total Reimbursement = 50 x $12.50 = $625.00

ML 103 • In contrast to ML 102, ML 103 requires three complexity factors. • In total, there are 10 complexity factors. Complexity Factors: • Two or more hours face-to-face. • Two or more hours record review. • Two or more hours of medical research (researching medical text books, not reading legal material or disability guidelines).

Complexity Factors • In many circumstances, complexity factors apply when a physician is required to spend an extended period of time conducting an evaluation. Complexity Factors: • Four or more hours spent on any combination of two of the above three complexity factors, which shall count as two complexity factors. • Six or more hours spent on any combination of complexity factor 1, 2, or 3, which shall count as three complexity factors.

Complexity Factors • In some instances, a physician may need to determine medical causation, or the cause of a worker’s injuries. Complexity Factors: • Addressing the issue of medical causation: • The party or parties who request the report may request an assessment of medical causation. • The evaluator may identify an issue regarding medical causation during the evaluation.

Complexity Factors • Sometimes a medical evaluator may be required to address apportionment. • Apportionment is a process used to determine which of a worker’s injuries are work-related, and therefore the employer’s responsibility. Complexity Factors: • Addressing the issue of apportionment: Applies when a physician must determine this issue by evaluating the claimant’s employment by three or more employers, three or more injuries to the same body system or body region, or two or more injuries involving two or more body systems or body regions.

Complexity Factors • During some evaluations, physicians may be required to monitor a patient, provide psychiatric services, or even address a previously denied treatment or claim. Complexity Factors: • Addressing the issue of medical monitoring following exposure to a toxic chemical, mineral, or biologic substance. • A psychiatric or psychological evaluation which is the primary focus of the med-legal evaluation. • Addressing the issue of denial or modification of treatment by the claims administrator following utilization review under LC 4610.

Much like modifiers, a physician must clearly indicate which of the complexity factors apply to the evaluation, and the circumstances under which each is applicable. Complexity Factors Additionally, complexity factor three (2 or more hours of medical research) must be justified by a list of citations of sources reviewed, and an excerpt from the source. Or, the physician must provide copies of the medical evidence used.

Example 1 Example 2 1 1 2 2 7 4 Complexity Factors • Now, let’s take a look at some examples of ML 103. If a physician... • Spends 2 hours face to face time with a patient • Completes two hours of record review • Addresses apportionment If a physician... • Spends 2 hours face-to-face with the patient • Completes 4 hours of record review The following complexity factors apply: The following complexity factors apply:

Example 2 Why do only two complexity factors qualify this as an example of ML 103 reimbursement? 1 2 4 Complexity Factors If a physician... • Spends 2 hours face-to-face with the patient • Completes 4 hours of record review Remember, complexity factor 4, which counts for two complexity factors, applies when 4 or more hours is spent on a combination of complexity factors 1-3. The following complexity factors apply:

ML 104 • ML104 is used to bill a comprehensive med legal evaluation that involves extraordinary circumstances. • ML104 applies in many different circumstances. ML 104: Comprehensive ML Evaluation Involving Extraordinary Circumstances RV: 5 (per each 15 minutes, or portion thereof, rounded to the nearest quarter hour) • Applies if four or more complexity factors were required to conduct an evaluation. • Applies if the physician evaluates prior multiple injuries to the same body part or parts and the evaluation requires three or more complexity factors, as well as three or more hours of record review.

ML 104 ML 104: Comprehensive ML Evaluation Involving Extraordinary Circumstances RV: 5 (per each 15 minutes, or portion thereof, rounded to the nearest quarter hour) • Applies if prior to a comprehensive medical-legal evaluation, the physician and requesting parties agree that the evaluation will involve extraordinary circumstances. Now let’s take a look at some examples...

Example 1 Example 2 1 1 2 2 4 4 ML 104 Dr. Johnson evaluates a patient who has incurred three different back injuries, all of which happened at different jobs. He discusses the injuries with the patient for 2 hours and reviews the patient’s extensive records from 3 pm until 6pm. Dr. Johnson evaluates a patient who has injured his knee and shoulder previously. He claims he injured his shoulder again, but this time on the job. Dr. Johnson discusses the patient’s injuries for two hours, and determines that the shoulder was re-injured at work. The following complexity factors apply: The following complexity factors apply: In addition to the three complexity factors, Dr. Johnson evaluates several prior injuries. Therefore, ML 104 is allowable. Although Dr. Johnson evaluated previous injuries, he did not review records for three or more hours. Therefore, ML 104 is not allowable.

Sometimes a physician may need to provide medical-legal testimony in order to resolve a contested claim. When a physician provides medical-legal testimony services, ML 105 is used. ML 105 ML 105: Fees for Medical Legal Testimony RV: 5 • Physicians are reimbursed per each 15 minutes, or portion thereof, rounded to the nearest quarter hour.

ML105 ML 105: Fees for Medical Legal Testimony RV: 5 • Physicians are reimbursed for all reasonable time spent on the testimony, including time devoted to preparation and travel. • The physician shall be paid a minimum of one hour for a scheduled deposition.

ML106 • ML106 is used when physicians provide supplemental medical-legal evaluations. ML 106: Fees for Supplemental Medical-Legal Evaluations RV: 5 • Physicians are reimbursed per each 15 minutes, or portion thereof, rounded to the nearest quarter hour.

ML 106 • Fees associated with supplemental reports are not reimbursable under some circumstances. Fees are not allowable when: • Supplemental reports include information that was available in the physician’s office for review. • The information was included in the initial medical record the physician reviewed to prepare his initial report. • Supplemental reports include information from laboratory or diagnostic tests ordered by the physician as part of his initial evaluation.

Modifiers Just like other types of service, modifiers are important to a med-legal evaluation. They further identify what type of service was performed, as well as change reimbursement. Let’s take a look…

Modifier -92 • Modifier –92 indicates services performed by a primary treating physician. -92 Performed by a Primary Treating Physician: This modifier is used for identification purposes only and does not change the normal reimbursement of the service.

Under some circumstances, communication between the injured worker and the physician is impaired. In these instances, Modifier –93 is used. Modifier -93 -93 Interpreter Needed at the Time of Examination: This modifier is used when an interpreter is needed at time of evaluation or under other circumstances, which impair communication between the physician and injured worker and significantly increase the time of service.

Modifier -93 • Documentation is required when Modifier –93 is billed. Documentation must: • Describe the circumstances under which the interpreter was necessary. • Describe the amount of time required for the evaluation as a result of the need for an interpreter. • Modifier –93 adjusts the normal reimbursement by multiplying the standard procedure reimbursement by 1.1. • This modifier is only applicable to ML102 and ML103.

Modifier -94 • Modifier –94 is used when an evaluation and med legal testimony is performed by an Agreed Medical Evaluator (AME). -94 Evaluation & Medical Legal Testimony Performed by an AME: Remember, an agreed medical evaluator is a physician appointed by attorneys and the claims administrator to perform a med legal evaluation and submit a report of his/her findings.

Modifier -94 Modifier –94 adjusts the normal reimbursement value for a procedure by a factor of 1.25. If Modifier -94 is applicable for ML102 or ML103, the value of the procedure is adjusted by a factor of 1.35.

In some instances a panel of people selects a Qualified Medical Examiner to perform a med legal evaluation. Modifier -95 • Remember, a qualified medical examiner is an independent physician who is certified to perform medical evaluations. -95 Evaluation Performed by a Panel-selected QME: This modifier does not affect reimbursement for services. Therefore, it is informational only.

How medical legal codes are used to bill for services. Medical Legal Services: An Overview Med Legal Evaluations: Who performs them and why they occur. How complexity factors affect reimbursement for med legal services. How various modifiers affect reimbursement for med legal services. Summary Contested Claims & Disputed Medical Facts

California Medical Bill Reviewer Re-Certification