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©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided.

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Presentation on theme: "©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided."— Presentation transcript:

1 ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care® California Medical Bill Reviewer Re-Certification Unit 3: Medical Legal Fee Schedule Module 1: Medical Legal Services Guidelines

2 2 March 2010 CA Regulations Training – Medical Legal Services Overview Medical Legal Services Medical Legal Evaluations Contested Claims Disputed Medical Facts Medical Legal Codes & Complexity Factors Modifiers 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. Medical Legal Services Lets start by discussing some general med legal guidelines...

3 3 March 2010 CA Regulations Training – Medical Legal Services Medical Legal Fee Schedule Up until this point, you have learned about different sections of the Official Medical Fee Schedule. In contrast to these sections, Medical Legal Services are covered in a separate fee schedule. Medical legal services are necessary when an aspect of an injury claim, a patients injury, or a patients diagnosis is contested.

4 4 March 2010 CA Regulations Training – Medical Legal Services Medical Legal Evaluations A medical legal evaluation is an evaluation of an employee to prove or disprove a contested claim. Medical legal evaluations are performed by: Qualified medical examiners Agreed medical evaluators Primary treating physicians Following a medical legal evaluation, a physician prepares a report which substantiates or disproves a disputed medical fact. You might not be familiar with the difference between a QME and an AME. Lets take a look...

5 5 March 2010 CA Regulations Training – Medical Legal Services 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. Medical Legal Evaluations Primary Treating Physician (PTP) Qualified Medical Examiner (QME) A qualified medical examiner is an independent physician who is certified to perform medical evaluations. Now lets take a look at the circumstances in which a medical legal evaluation may be necessary. You might recall that the primary treating physician is the physician responsible for overseeing the total care of an injured worker.

6 6 March 2010 CA Regulations Training – Medical Legal Services Medical Legal Evaluations Two concepts important to your understanding of medical legal evaluations are: Contested ClaimsDisputed Medical Facts Lets take a look…

7 7 March 2010 CA Regulations Training – Medical Legal Services Circumstance 4 A claim for which a claims administrator accepts liability for the claim, but a disputed medical fact exists. Circumstance 3 Contested claims can occur under different circumstances. A claim for which a claims administrator has failed to respond to a demand for payment of indemnity benefits. Contested Claims Circumstance 1 Circumstance 2 A claim for which a claims administrator has failed to accept liability. A claim for which a claims administrator rejects liability.

8 8 March 2010 CA Regulations Training – Medical Legal Services The dispute may concern: An employees medical condition. The cause of the medical condition. The treatment for the medical condition. The existence, nature, duration, or extent of disability caused by employees medical condition. The medical eligibility for rehabilitation services. 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.

9 9 March 2010 CA Regulations Training – Medical Legal Services Medical Legal Codes Lets take a look… Just like other types of service, med-legal services have a specific set of codes by which reimbursement is determined.

10 10 March 2010 CA Regulations Training – Medical Legal Services Medical Legal Codes 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. RV x $ Applicable Modifiers = Med Legal Reimbursement

11 11 March 2010 CA Regulations Training – Medical Legal Services 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. Lets take a look…

12 12 March 2010 CA Regulations Training – Medical Legal Services ML 100 ML 100 indicates a missed appointment for a comprehensive or follow-up med legal evaluation. Therefore, reimbursement is at the discretion of the claims administrator. This code does not necessitate payment. What might this mean? This code is informational only.

13 13 March 2010 CA Regulations Training – Medical Legal Services 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 providers 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.

14 14 March 2010 CA Regulations Training – Medical Legal Services 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

15 15 March 2010 CA Regulations Training – Medical Legal Services ML 103 In contrast to ML 102, ML 103 requires three complexity factors. Complexity Factors: 1.Two or more hours face-to-face. 2.Two or more hours record review. 3.Two or more hours of medical research (researching medical text books, not reading legal material or disability guidelines). In total, there are 10 complexity factors.

16 16 March 2010 CA Regulations Training – Medical Legal Services 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: 4.Four or more hours spent on any combination of two of the above three complexity factors, which shall count as two complexity factors. 5.Six or more hours spent on any combination of complexity factor 1, 2, or 3, which shall count as three complexity factors.

17 17 March 2010 CA Regulations Training – Medical Legal Services Complexity Factors In some instances, a physician may need to determine medical causation, or the cause of a workers injuries. Complexity Factors: 6.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.

18 18 March 2010 CA Regulations Training – Medical Legal Services Complexity Factors Sometimes a medical evaluator may be required to address apportionment. Complexity Factors: 7.Addressing the issue of apportionment: Applies when a physician must determine this issue by evaluating the claimants 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. Apportionment is a process used to determine which of a workers injuries are work-related, and therefore the employers responsibility.

19 19 March 2010 CA Regulations Training – Medical Legal Services 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: 8.Addressing the issue of medical monitoring following exposure to a toxic chemical, mineral, or biologic substance. 9.A psychiatric or psychological evaluation which is the primary focus of the med-legal evaluation. 10.Addressing the issue of denial or modification of treatment by the claims administrator following utilization review under LC 4610.

20 20 March 2010 CA Regulations Training – Medical Legal Services Complexity Factors 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. 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.

21 21 March 2010 CA Regulations Training – Medical Legal Services Example 1 Complexity Factors Now, lets take a look at some examples of ML If a physician... Spends 2 hours face to face time with a patient Completes two hours of record review Addresses apportionment The following complexity factors apply: Example 2 If a physician... Spends 2 hours face-to-face with the patient Completes 4 hours of record review 124 The following complexity factors apply:

22 22 March 2010 CA Regulations Training – Medical Legal Services Complexity Factors Example 2 If a physician... Spends 2 hours face-to-face with the patient Completes 4 hours of record review 124 The following complexity factors apply: Why do only two complexity factors qualify this as an example of ML 103 reimbursement? 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.

23 23 March 2010 CA Regulations Training – Medical Legal Services ML 104 ML104 is used to bill a comprehensive med legal evaluation that involves extraordinary 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. ML104 applies in many different circumstances.

24 24 March 2010 CA Regulations Training – Medical Legal Services 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 lets take a look at some examples...

25 25 March 2010 CA Regulations Training – Medical Legal Services ML 104 Example 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 patients extensive records from 3 pm until 6pm. The following complexity factors apply: In addition to the three complexity factors, Dr. Johnson evaluates several prior injuries. Therefore, ML 104 is allowable. Example 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 patients injuries for two hours, and determines that the shoulder was re- injured at work. The following complexity factors apply: Although Dr. Johnson evaluated previous injuries, he did not review records for three or more hours. Therefore, ML 104 is not allowable.

26 26 March 2010 CA Regulations Training – Medical Legal Services ML 105: Fees for Medical Legal Testimony RV: 5 ML 105 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. Physicians are reimbursed per each 15 minutes, or portion thereof, rounded to the nearest quarter hour.

27 27 March 2010 CA Regulations Training – Medical Legal Services 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.

28 28 March 2010 CA Regulations Training – Medical Legal Services 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.

29 29 March 2010 CA Regulations Training – Medical Legal Services 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 physicians 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.

30 30 March 2010 CA Regulations Training – Medical Legal Services Modifiers Lets take a look… 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.

31 31 March 2010 CA Regulations Training – Medical Legal Services 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.

32 32 March 2010 CA Regulations Training – Medical Legal Services Modifier -93 Under some circumstances, communication between the injured worker and the physician is impaired. In these instances, Modifier –93 is used. -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.

33 33 March 2010 CA Regulations Training – Medical Legal Services Modifier -93 Documentation is required when Modifier –93 is billed. Documentation must: Describe the circumstances under which the interpreter was necessary. Modifier –93 adjusts the normal reimbursement by multiplying the standard procedure reimbursement by 1.1. This modifier is only applicable to ML102 and ML103. Describe the amount of time required for the evaluation as a result of the need for an interpreter.

34 34 March 2010 CA Regulations Training – Medical Legal Services 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.

35 35 March 2010 CA Regulations Training – Medical Legal Services Modifier –94 adjusts the normal reimbursement value for a procedure by a factor of Modifier -94 If Modifier -94 is applicable for ML102 or ML103, the value of the procedure is adjusted by a factor of 1.35.

36 36 March 2010 CA Regulations Training – Medical Legal Services Modifier -95 In some instances a panel of people selects a Qualified Medical Examiner to perform a med legal evaluation. -95 Evaluation Performed by a Panel-selected QME: This modifier does not affect reimbursement for services. Therefore, it is informational only. Remember, a qualified medical examiner is an independent physician who is certified to perform medical evaluations.

37 37 March 2010 CA Regulations Training – Medical Legal Services Summary Medical Legal Services: An Overview Med Legal Evaluations: Who performs them and why they occur. Contested Claims & Disputed Medical Facts How medical legal codes are used to bill for services. How complexity factors affect reimbursement for med legal services. How various modifiers affect reimbursement for med legal services.


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