Reimbursement for time spent preparing medical-legal evaluation reports is always billable when code ML104 is applied compliantly. A recent lawsuit, Howard, et al. v. California DIR clarified this.
There are three scenarios when a medical-legal evaluator may bill ML104:
If the medical-legal evaluation report addresses four or more of the “complexity factors” described in the regulations for ML103 (Complex Comprehensive Medical-Legal Evaluation), or
- If the medical-legal evaluation report addresses multiple injuries to the body part(s) being evaluated AND the report address three or more of the ML103 “complexity factors,” or
- If the physician and the parties agree that “extraordinary circumstances” are present.
In all three scenarios, time spent preparing reports is billable and should be included in the medical-legal evaluation report verification.
In the Howard lawsuit settlement, the DWC reversed their previous position, which held that report preparation time is only billable in scenario #3, when the parties agree. This incorrect interpretation was the result of a DWC clerical error.
No matter the scenario, report preparation is always billable and reimbursable when ML104 is the appropriate billing code. However, it’s important to remember that report preparation time is not a complexity factor, and may not be used to qualify a medical-legal evaluation for ML104.
Complexity factors include:
- Two or more hours of face-to-face time with the injured worker
- Two or more hours of record review
- Two or more hours of medical research
- Four or more hours spent on a combination of any two of complexity factors 1 through 3.
- Six or more hours spent on a combination of all three complexity factors 1 through 3
- Addressing medical causation
- Addressing apportionment, under certain specific circumstances
- A primarily psychiatric or psychological evaluation
Providers sometimes mistakenly consider excessive report preparation time a complexity factor and use that time to qualify an examination for ML104. This is non-compliant.
Providers may (and should) bill for time spent preparing the medical-legal evaluation report, but ONLY if the provider has qualified the medical-legal evaluation for ML104 based on the criteria described here.