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ADVISORY 2004-01

SUBJECT: Billing and Reimbursement for Maximum Medical Improvement (MMI) and Impairment Rating (IR) Services

The Texas Workers' Compensation Commission (the Commission) provides clarification concerning the billing and reimbursement of Commission specific services relating to Maximum Medical Improvement (MMI) and Impairment Ratings (IR) as found in Rule 134.202 (e)(6), Medical Fee Guideline (MFG), that became effective on August 1, 2003.


Unlike previous MFGs, the 2002 MFG sets reimbursement for assignment of IRs based on the method used to assign the IR: range of motion (ROM) method or diagnostic related estimate (DRE) method. It is not possible to determine which method was used to determine the IR by only reading the CPT code. The insurance carrier (carrier) must read the report describing the calculation of the IR in order to determine which method was used to assign the IR and to reimburse the health care providers appropriately.

If a treating doctor determines that no permanent impairment exists as a result of the compensable injury, the treating doctor does not perform an examination for the purpose of calculating an IR and is not reimbursed for assigning an IR. In this situation, the treating doctor uses the CPT code for "Work related or medical disability examination by the treating physician..." and the appropriate "V" modifier. However, if the treating doctor believes that there is or may be permanent impairment as a result of the compensable injury, both the certification of MMI and the assignment of an impairment rating must be done by a doctor who is authorized to assign impairment ratings and the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition (the Guides) must be used. When application of the Guides results in an IR of zero percent after an appropriate examination, the rating doctor and any ancillary health care provider shall be reimbursed for the calculation of the zero IR in addition to the reimbursement for the determination of MMI. In this situation, the treating doctor uses the CPT code for "Work related or medical disability examination by the treating physician...", the appropriate "V" modifier, and any additional modifiers that are required to describe the IR examination. As stated in Rule 130.1 (c) (1), "A zero percent impairment may be a valid rating." "No impairment" means the injury was minor and the Guides were not used. "Zero impairment" means the Guides were used and the results are that there is zero percent impairment.

Billing and reimbursement when there is no test to determine the Impairment Rating (IR).

The MFG has billing instructions for musculoskeletal and non-musculoskeletal areas. The non-musculoskeletal areas are reimbursed using the appropriate CPT code(s) for the test(s) required for the assignment of an IR. In addition, if the examination for the determination of MMI and/or the assignment of IR requires testing that is not outlined in the Guides, the appropriate CPT code(s) shall be billed and reimbursed in addition to the fees outlined in Rule 134.202 (e) (6)(C) and (D).

There are non-musculoskeletal conditions such as hernias of the abdominal wall and skin disorders for which there is no test to determine an IR. There are other conditions that fall into this category also, but these two examples are common to work related injuries. The IR for these injuries comes from charts in the Guides, using information from the maximum medical improvement (MMI) examination of the injured employee but with no additional tests. These charts generally show a category of impairment and a range of ratings that fall into that category. The ranges are expressed in terms such as "0 %- 9%, 10%-19%, and 20%- 30%." The impairment-rating doctor must assign a finite whole number rating from the range of ratings.

While there is no additional test to assign the IR, the doctor performing the IR is required to use good medical judgment when assigning the IR and must be prepared to defend and clarify the decision to assign a finite impairment rating from the range of ratings given. Because using these charts to assign an IR is equivalent to assigning an IR by the DRE method or injury model, this type of IR is reimbursed at $150 per DRE area. Both of the above fees are reimbursed in addition to the $350 paid for the MMI evaluation.

Billing and reimbursement for multiple IRs when extent of injury is disputed

A Designated Doctor may learn of the pending dispute concerning the extent of a compensable injury from documentation provided by the treating doctor and/or carrier or the comments of the employee regarding his/her injury. When the Designated Doctor learns that the extent of an injury being rated has been disputed, the Designated Doctor is required by Rule 130.6(d)(5) to assign multiple certifications of MMI and impairment ratings that take into account the various interpretations of the extent of injury.

The Medical Fee Guideline (MFG) has the following billing instructions for multiple IRs in this situation:

(ii) When multiple IRs are required as a component of a Designated Doctor examination under §130.6 of this title (relating to Designated Doctor Examinations for Maximum Medical Improvement and/or Impairment Ratings), the Designated Doctor shall bill for the number of body areas rated and be reimbursed $50 for each additional IR calculation. Modifier "MI" shall be added to the MMI evaluation CPT code.

The following is an example of proper billing and reimbursement in the situation where multiple impairment ratings are required based on pending extent of injury disputes:

A Designated Doctor is selected by the Commission to perform an examination to determine whether or not the injured employee has reached MMI, and if so, assigns an impairment rating. During the examination and review of records the Designated Doctor determines the employee is claiming an injury to the right knee and right elbow and the carrier is disputing the injury to the right elbow.

The Designated Doctor must examine the employee to: 1) determine if the employee has reached MMI considering only the accepted body part (right knee), and if so, assign a whole body impairment rating, and 2) determine if the employee has reached MMI considering both body parts together, and if so, assign impairment ratings for both body parts, and combine those ratings into a whole body impairment rating.

The Designated Doctor may bill and be reimbursed for the MMI evaluation ($350) plus the assignment of an IR of first body area (lower extremity). In addition, the Designated Doctor may bill and be reimbursed $50 for the additional impairment rating of the disputed area (upper extremity) using the "-MI" modifier.

Billing and Reimbursement for Designated Doctor (DD) examination when only IR is in dispute

When the impairment rating is the only issue in dispute, the Designated Doctor (DD) shall assign an impairment rating without considering the MMI date. Before assigning the IR, the DD is required to review the medical records and films and to examine the injured employee. After examining the employee and obtaining the medical information necessary to calculate the IR, the doctor is required to prepare and submit reports (including the narrative report, and any response to requests for further clarification, explanation, or reconsideration). Although the DD does not address MMI date in the report of examination, the DD is still required to perform a similar level of service as though both MMI and IR were in dispute. Because the medical examination and administrative requirements associated with assigning only an IR are similar to that required for assigning both MMI and an IR, the doctor is to be reimbursed $350 (the amount that would be reimbursed for the MMI examination by itself) plus reimbursement for the assignment of impairment rating(s).

Signed on this 25th day of March, 2004

Richard F. Reynolds, Executive Director

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