Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director - Administrative Rules
Article 5.3. Official Medical Fee Schedule
(a) Maximum fees for physicians and qualified non-physician practitioners performing consultation services shall be determined utilizing the appropriate RVU for a patient evaluation and management visit and the RVU(s) for prolonged service codes if warranted under CPT guidelines. Physicians and qualified non-physician practitioners shall code consultation visits as patient evaluation and management visits utilizing the CPT Evaluation and Management codes that represent where the visit occurs and that identify the complexity of the visit performed. CPT consultation codes shall not be utilized.
(1) In the inpatient hospital setting and the nursing facility setting consulting physicians (and qualified non-physician practitioners where permitted) who perform an initial evaluation may bill the initial hospital care codes (99221-99223) or nursing facility care codes (99304-99306).
Follow-up consultation visits in the inpatient hospital setting shall be billed as subsequent hospital care visits (99231-99233) and subsequent nursing facility care visits (99307-99310.)
(2) In the office or other outpatient setting where a consultation / evaluation is performed, physicians and qualified non-physician practitioners shall use the CPT visit codes (99201-99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician, as defined in section 9789.12.11.
(b) Consultation reports are bundled into the underlying evaluation and management visit code or hospital care code, and are not separately payable, except as specified in subdivision (c).
(c) The following consultation reports are separately reimbursable:
(1) Consultation reports requested by the Workers' Compensation Appeals Board or the Administrative Director. Use WC007, modifier -32.
(2) Consultation reports requested by the Qualified Medical Evaluator (“QME”) or Agreed Medical Evaluator (“AME”) in the context of a medical-legal evaluation. Use WC007, modifier -30.
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
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).
2. Amendment of subsection (b) filed 11-6-2018; operative 1-1-2019. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2018, No. 45).