Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.6. Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations

§ 9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony.

(a) The schedule of fees set forth in this section shall be prima facie evidence of the reasonableness of fees charged for medical-legal evaluation reports, and fees for medical-legal testimony. Reports by treating or consulting physicians, other than comprehensive, follow-up or supplemental medical-legal evaluations, regardless of whether liability for the injury has been accepted at the time the treatment was provided or the report was prepared, shall be subject to the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1 rather than to the fee schedule set forth in this section.

(b) The fee for each evaluation is calculated by multiplying the relative value by $16.25, and adding any amount applicable because of the modifiers permitted under subdivision (d). The fee for each medical-legal evaluation procedure includes reimbursement for the history and physical examination, review of records, preparation of a medical-legal report, including typing and transcription services, and overhead expenses. The complexity of the evaluation is the dominant factor determining the appropriate level of service under this section; the times to perform procedures is expected to vary due to clinical circumstances, and is therefore not the controlling factor in determining the appropriate level of service.

(c) Medical-legal evaluation reports and medical-legal testimony shall be reimbursed as follows:

CODE	RV	PROCEDURE DESCRIPTION
ML200	31	Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation.
	($503.75)	Includes Includes instances where the injured worker does not show up for the evaluation, the interpreter does not show up for the evaluation which makes it impossible to go forward with the exam, the injured worker leaves the evaluation before the completion of the evaluation, the injured worker is more than 30 minutes late for the appointment and the QME is unable to continue with the scheduled QME appointment, or in the case where the appointment has been canceled within six business days of the scheduled appointment date. If the physician produces a record review report within 30 days of the date of the missed appointment the physician shall be reimbursed at the rate of $3.00 per page for any records reviewed in excess of 200 pages. When billing for a record review report under this code, the physician shall include in the report a verification under penalty of perjury of the total number of pages of records reviewed by the physician as part of the medical-legal evaluation and preparation of the report. Any pages reviewed for this record review report will be excluded from the page count for reimbursement when the face-to-face or supplemental evaluation takes place.
If fees for failed appointments and for late cancellations are incurred through the fault or neglect of the injured worker or his/her representative, the employer may seek to credit those charges against the injured worker's award.
ML201	124	Comprehensive Medical-Legal Evaluation
	($2,015)	Includes all comprehensive medical- legal evaluations that do not qualify as follow-up or supplemental medical- legal evaluations. The fee includes review of 200 pages of records. Review of records in excess of 200 pages shall be reimbursed at the rate of $3.00 per page. When billing under this code, the physician shall include in the report a verification under penalty of perjury of the total number of pages of records reviewed by the physician as part of the medical-legal evaluation and preparation of the report.
ML202	81	Follow-up Medical-Legal Evaluation.
	($1,316.25)	Limited to a follow-up medical-legal evaluation by a physician which occurs within eighteen months of the date on which a prior comprehensive medical-legal evaluation was performed by the same physician. The fee includes review of 200 pages of records that were not reviewed as part of the initial comprehensive medical-legal evaluation or as part of any intervening supplemental medical-legal evaluations. Review of records in excess of 200 pages that were not reviewed as part of the initial comprehensive medical-legal evaluation or as part of any intervening supplemental medical-legal evaluations shall be reimbursed at the rate of $3.00 per page. When billing under this code, the physician shall include in the report a verification under penalty of perjury of the total number of pages of records reviewed by the physician as part of the medical-legal evaluation and preparation of the report.
ML203	40	Fees for Supplemental Medical-Legal Evaluations.
	($650)	The fee includes services for writing a report after receiving a request for a supplemental report from a party to the action or receiving records that were not available at the time of the initial or follow-up comprehensive medical-legal evaluation. Fees will not be allowed under this section for supplemental reports: (1) following the physician's review of information which was available in the physician's office for review or was included in the medical record provided to the physician prior to preparing a comprehensive medical- legal report or a follow-up medical-legal report; or (2) addressing an issue that was requested by a party to the action to be addressed in a prior comprehensive medical-legal evaluation, a prior follow- up medical-legal evaluation, or a prior supplemental medical-legal evaluation. Failure to issue a supplemental report upon request because of an inability to bill for the report under this code would constitute grounds for discipline by the Administrative Director or his or her designee. The fee includes review of 50 pages of records. Review of records in excess of 50 pages that were received as part of the request for the supplemental report shall be reimbursed at the rate of $3.00 per page. When billing under this code, the physician shall include in the report a verification under penalty of perjury of the total number of pages of records reviewed by the physician as part of the supplemental medical-legal$ evaluation and preparation of the report.
ML204	7	Fees for Medical-Legal Testimony.
	($455/hr)	The physician shall be reimbursed at the rate of RV 7, or his or her usual and customary fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician. The physician shall be entitled to fees for all itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time. The physician shall be paid a minimum of two hours for a deposition. If a deposition is canceled fewer than eight (8) calendar days before the scheduled deposition date, the physician shall be paid a minimum of one hour for the scheduled deposition.
ML205	5	Fees for Review of Sub Rosa Recordings.
	($325/hr)	The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary hourly fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician for time spent reviewing sub rosa recordings. The physician shall include in his or her report verification under penalty of perjury of time spent reviewing sub rosa recordings. The fee for reviewing sub rosa recordings may be allowed in addition to any fee for any single report written by the physician as a result of the review of the sub rosa recordings. If the sub rosa recordings are received by a physician prior to the issuance of a pending report related to a medical-legal evaluation, the physician may not also bill a supplemental report fee in connection with the review of the sub rosa material.

CODE	B.R.	PROCEDURE DESCRIPTION
ML-PRR	($3.00 per page)	Record Review.
	This billing code used to identify charges for review of records in excess of pages included in medical-legal numerical billing codes. Excess pages are billed at three dollars per page.

(d) The services described by Procedure Codes ML-201 through ML-203 may be modified under the circumstances described in this subdivision. The modifiers shall not be applicable to per page charges for record review in any of the Procedure Codes ML-201 through ML-203. The modifying circumstances shall be identified by the addition of the appropriate modifier code, which is reported by a two-digit number placed after the usual procedure number separated by a hyphen. The modifiers available are the following:

-92 Performed by a primary treating physician. This modifier is added solely for identification purposes, and does not change the normal value of the service.

-93 Interpreter needed at time of examination, or other circumstances which impair communication between the physician and the injured worker and significantly increase the time needed to conduct the examination. Requires a description of the circumstance and the increased time required for the examination as a result. Where this modifier is applicable, the value for the procedure is modified by multiplying the normal value by 1.1. This modifier shall only be applicable to ML- 201 and ML-202.

-94 Evaluation performed by an Agreed Medical Evaluator. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.35. If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.45.

-95 Evaluation performed by a panel selected Qualified Medical Evaluator. This modifier is added solely for identification purposes, and does not change the normal value of any procedure.

-96 Evaluation performed by a Psychiatrist or Psychologist when a psychiatric or psychological evaluation is the primary focus of the medical-legal evaluation. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 2. If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.10. If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.35. If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.45.

-97 Evaluation performed by a physician who is board certified in Toxicology, a physician who is certified as a Qualified Medical Evaluator in the specialty of Internal Medicine or a physician who is board certified in Internal Medicine, when a Toxicology evaluation is the primary focus of the medical-legal evaluation. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.50. If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.60. If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.85. If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.95.

-98 Evaluation performed by a physician who is board certified in Medical Oncology, a physician who is certified as a Qualified Medical Evaluator in the specialty of Internal Medicine or a physician who is board certified in Internal Medicine, when an Oncology evaluation is the primary focus of the medical-legal evaluation. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.50. If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.60. If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.85. If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.95.

(e) Requests for duplicate reports shall be in writing. Duplicate reports shall be separately reimbursable and shall be reimbursed in the same manner as set forth in the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1.

(f) This section shall be effective as of April 1, 2021 and shall apply to the following: (1) medical-legal evaluation reports where the examination occurs on or after April 1, 2021; (2) medical-legal testimony provided on or after April 1, 2021; and (3) supplemental medical legal reports that are requested on or after April 1, 2021 regardless of the date of the original examination.

(g) Nothing in this regulation affects the operation of Labor Code section 5307.6.

(h) If a medical-legal evaluation is ordered by an administrative law judge or court of competent jurisdiction, the judge has the authority to apply the appropriate modifier to that medical-legal evaluation for purposes of billing.

Note: Authority cited: Sections 133, 4627, 5307.3 and 5307.6, Labor Code. Reference: Sections 139.2, 4061, 4061.5, 4062, 4610.5, 4620, 4621, 4622, 4625, 4626, 4628, 5307.6 and 5402, Labor Code.

HISTORY

1. Repealer and new section filed 8-3-93; operative 8-3-93. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 32).

2. Change without regulatory effect amending subsection (a) and subsection (c) medical-legal evaluation procedure code ML104 filed 8-27-93 pursuant to section 100, title 1, California Code of Regulations (Register 93, No. 35).

3. Amendment of section heading, section and Note filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53).

4. Amendment filed 2-24-99; operative 4-1-99 (Register 99, No. 9).

5. Change without regulatory effect amending subsections (b) and (d) filed 6-12-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 24).

6. Amendment of section and Note filed 6-30-2006; operative 7-1-2006. Submitted to OAL for filing with the Secretary of State and printing only pursuant to Government Code section 11340.9(g) (Register 2006, No. 26).

7. Amendment of subsection (c) (medical-legal evaluation procedure code ML103) and amendment of Note filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL by 7-1-2013 or emergency language will be repealed by operation of law on the following day.

8. Amendment of subsection (c) (medical-legal evaluation procedure code ML103) and amendment of Note refiled 7-1-2013 as an emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2013 or emergency language will be repealed by operation of law on the following day.

9. Amendment of subsection (c) (medical-legal evaluation procedure code ML103) and amendment of Note refiled 9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency language will be repealed by operation of law on the following day.

10. Certificate of Compliance as to 9-30-2013 order, including further amendment of subsection (c) (medical-legal evaluation code ML103), transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective 2-12-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 7).

11. Amendment of subsections (b)-(d) and (f) and new subsections (g)-(h) filed 3-30-2021; operative 4-1-2021. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2021, No. 14).