Understanding the Updated Medical-Legal Fee Schedule for California Workers’ Compensation
At Meraki RCM Solutions, LLC, we are dedicated to providing clear, comprehensive guidance on the latest changes in medical billing practices. The Medical-Legal Fee Schedule (MLFS) in California has seen significant updates effective from April 1, 2021. These changes are crucial for medical service providers involved in workers’ compensation cases, and our aim is to offer a detailed overview of these revisions to enhance your billing processes.
Key Updates to the Medical-Legal Fee Schedule
New Billing Codes and Their Implications
ML200 – Missed Appointment Charges This code addresses charges for missed appointments involving comprehensive or follow-up Medical-Legal Evaluations. A fee of $503.75 is applied to scenarios such as the injured worker or an interpreter failing to appear, or cancellations made too close to the scheduled date.
ML201 – Comprehensive Medical-Legal Evaluation Charged at $2,015, this code covers evaluations that serve as the initial assessment for a case, excluding any follow-up or supplemental evaluations.
ML202 – Follow-Up Medical-Legal Evaluation This involves evaluations conducted within eighteen months of a comprehensive evaluation by the same physician, with a fee of $1,316.25.
ML203 – Supplemental Medical-Legal Evaluation At a cost of $650, this code is used for evaluations based on new requests or information that was not available during earlier assessments.
ML204 – Medical-Legal Testimony Compensation for this time-based service is $113.75 per 15-minute increment, covering all aspects related to providing testimony, including preparation and travel.
ML205 – Sub Rosa Recording Review This also follows a time-based reimbursement model, with $81.25 per 15-minute increment charged for the review of surveillance recordings that are relevant to the case.
MLPRR – Record Review This service is charged at $3.00 per page when the documents reviewed exceed the standard page limits included in medical-legal evaluations.
Detailed Application of Billing Codes
Missed Appointments (ML200) The fee applies under several conditions, such as non-attendance by the injured worker, Interpreter, injured workers leave the evaluation before completion, injured worker is late for appointment more than 30 mins, appointment is cancelled within 6 business days of appointment.
Comprehensive Evaluations (ML201) This code encompasses all first-time evaluations that do not require follow-up or supplemental reports, providing a foundational assessment of the worker’s medical condition.
Follow-Up Evaluations (ML202) Reserved for assessments by the same physician who conducted the initial evaluation, ensuring continuity in the evaluation process.
Supplemental Evaluations (ML203) This code is for additional evaluations or record reviews necessitated by new or previously unavailable data that impacts the case.
Record Review Standards
Under the new MLFS, a strict protocol for record review ensures that every document reviewed meets certain standards, including a declaration of compliance with Labor Code section 4062.3. Each document set reviewed must be accompanied by a declaration under penalty of perjury, verifying compliance and providing an accurate page count.
Enhanced Understanding of New Modifier Rules in the Updated MLFS
In the updated Medical-Legal Fee Schedule (MLFS), one of the significant revisions involves the application and addition of billing code modifiers. These modifiers, ranging from -92 to -98, allow physicians to adjust billing based on specific circumstances encountered during medical evaluations. This section provides a detailed overview of each modifier and how they can be applied to enhance billing accuracy for services rendered.
Application of Billing Code Modifiers
Modifier -92: Identification for Primary Treating Physician (PTP) This modifier is used solely for identification purposes and does not influence the reimbursement amount. It indicates that the evaluation was performed by the primary treating physician.
Modifier -93: Adjustments for Required Interpreters or Impaired Communication When an evaluation requires an interpreter or if other communication barriers significantly extend the evaluation time, modifier -93 is applicable. It increases the normal reimbursement rate by 10% (multiplied by 1.1). This modifier is only applicable to billing codes ML201 and ML202, reflecting the extra time and resources needed.
Modifier -94: Agreed Medical Evaluation (AME) This modifier is used when an evaluation is performed by an Agreed Medical Evaluator. It enhances the reimbursement rate by 35% (multiplied by 1.35). If used in conjunction with modifier -93, the increase goes up to 45% (multiplied by 1.45), acknowledging the combined complexities and additional time required.
Modifier -95: Panel-Selected Qualified Medical Evaluator (QME) Used strictly for identification, modifier -95 signifies that the evaluation was conducted by a QME selected from a panel. It does not alter the reimbursement rate but is important for record-keeping and procedural transparency.
Modifier -96: Specialized Psychiatric or Psychological Evaluations When the primary focus of an evaluation is psychiatric or psychological, modifier -96 doubles the standard reimbursement (multiplied by 2). This reflects the specialized nature of these assessments. If combined with modifiers -93 and -94, the reimbursement can increase up to 245% of the base rate, accommodating the additional complexities involved.
Modifier -97: Specialized Toxicology Evaluations This modifier is applied when the evaluation primarily focuses on toxicology, conducted by a physician who are Board certified in Toxicology or Internal Medicine. It increases the base rate by 50% (multiplied by 1.5). When other complications like language barriers (modifier -93) or additional evaluator agreements (modifier -94) are present, the rate increases further to account for these factors.
Modifier -98: Specialized Oncology Evaluations For evaluations centered around oncology, conducted by a board-certified Medical Oncologist or similarly qualified physician, modifier -98 increases the reimbursement by 50% (multiplied by 1.5). This adjustment acknowledges the specialized expertise and the critical nature of oncology evaluations
Conclusion
The updates to the MLFS are designed to streamline the billing process for medical-legal services in California's workers' compensation system. By familiarizing yourself with these changes, healthcare providers can ensure accurate billing and adequate reimbursement for their services. At Meraki RCM Solutions, LLC, we are here to help you navigate these changes effectively, ensuring that your billing practices are both compliant and efficient.
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