Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule

§9789.12.11. Evaluation and Management: Coding - New Patient; Documentation.

(a) For purposes of workers' compensation billing, the following definitions of “new patient” and “established patient” will be used instead of the CPT definitions:

(1) A “new patient” is one who is new to the physician or medical group or an established patient with a new industrial injury or illness. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury or illness.

(2) An “established patient” is a patient who has been seen previously for the same industrial injury or illness by the physician or medical group.

(b) To properly document and determine the appropriate level of evaluation and management service, physicians and qualified non-physician practitioners must use either one of the following guidelines but not a combination of the two guidelines for a patient encounter. If the physician's or qualified non-physician practitioner's documentation for a medically necessary service conforms to either one of the guidelines, the maximum reasonable fee shall be according to the documented level of service:

(1) The “1995 Documentation Guidelines for Evaluation & Management Services,” or

(2) The “1997 Documentation Guidelines for Evaluation and Management Services.”

Both guidelines are incorporated by reference and are available on Medicare's website, or will be made available upon request to the Administrative Director.

The 1995 version is available at https://www.cms.gov/Outreach -and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/ Downloads/95Docguidelines.pdf

The 1997 version is available at https://www.cms.gov/ Outreach-and-Education/Medic are-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.

HISTORY

1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).