This article explains the circumstances under which a consultation report is reimbursable. We also include links to the relevant regulatory codes for reference.

Explanation

Per section 9789.12.12, there are two situations when a consultation report is reimbursable. Both require the use of California-specific billing codes. The two situations when a report is reimbursable are:

1. If the Workers’ Compensation Appeals Board (WCAB) or the Administrative Director requests a consultation report, then the report is reimbursable and should be billed with the new California-specific code WC007 with a modifier -32. Reimbursement for WC007 is $38.99 for first page and $23.99 for each additional page. A maximum of six pages is allowable, absent mutual agreement (for a total maximum reimbursement of $158.94).
2. If the Qualified Medical Evaluator (QME) or the Agreed Medical Evaluator (AME) requests the consultation and an accompanying consultation report. Under these circumstances the modifier -30 should be appended to the code WC007.

Additional Information

California Code of Regulations § 9789.12.12 Consultation Services Coding - Use of Visit Codes

Official Medical Fee Schedule

DaisyBill Resources

Webinar: Workers’ Compensation Fee Schedules

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