The UR determined that codes 23412 and 23120 performed on 11/18/2015 should be reimbursed based on guidelines. The claims administrator had denied reimbursement indicating pre-authorization was required and visit limits were reached. However, the UR documentation approved the procedures performed. As documentation supported the codes, reimbursement was warranted.

1. 0232T-RT Claims Administrator denied code
with rationale “ Included in another
billed procedure.”
Claims Administrator denied code with rationale “ Included in another billed procedure.”
UR Determination dated 09/02/2015 received certified 1PRP injection between 8/27/2015 and 8/27/2016.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Documentation dated 9/2/2015 is contract in nature.
0232T has a listed Multiple procedure indicator: “0.” Multiple Procedure Payment adjustment is not applicable.
0232T Reflects Zero Value under OMFS. As such, 0232T is a By Report Code and reimbursement is based on one of the
following: contractual agreement, documented paid cost, or the Providers usual and customary fee.
Assigned Status Code for 0232T is ‘C.”
§ 9789.12.3 Status Codes C, I, N and R
o(a) Except as otherwise provided in this fee schedule, for physician and non-physician practitioner services billed using Current
Procedural Terminology (CPT) codes, the RVUs listed in the Centers for Medicare and Medicaid Services (CMS’) National
Physician Fee Schedule Relative Value File will be utilized regardless of status code.
o(b) When procedures with status indicator codes C, N, or R, do not have RVUs assigned under the CMS’ National Physician
Fee Schedule Relative Value File, these services shall be reimbursed By Report.
Review of the operative report, services were performed and documented.
Opportunity for Claims Administrator to Dispute letter sent on 1/25/2016. A response from Claims Administrator was not
received for this review.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for the billed code 232T-
RT
.
0232T-RT and
0232T-LT
Claims Administrator reimbursed
both codes with rationale “The
Official Medical Fee Schedule does
not list this code. An allowance has
been made for a comparable
service.”
Provider seeking additional remuneration for 0232T-RT and 0232T –LT Platelet Plasma Injection service performed on Injured
Worker 05/28/2015.
Claims Administrator reimbursed both codes with rationale “The Official Medical Fee Schedule does not list this code. An
allowance has been made for a comparable service.”
UR Determination received certified 1PRP injections to bilateral knees between 4/25/2015 and 8/28/2015.

2. 0232T has a listed Multiple procedure indicator: “0.” Multiple Procedure Payment adjustment is not applicable.
0232T Reflects Zero Value under OMFS. As such, 0232T is a By Report Code and reimbursement is based on one of the
following: contractual agreement, documented paid cost, or the Providers usual and customary fee.
A contract agreement not received for this review.
Assigned Status Code for 0232T is ‘C.”
§ 9789.12.3 Status Codes C, I, N and R
o(a) Except as otherwise provided in this fee schedule, for physician and non-physician practitioner services billed using Current
Procedural Terminology (CPT) codes, the RVUs listed in the Centers for Medicare and Medicaid Services (CMS’) National
Physician Fee Schedule Relative Value File will be utilized regardless of status code.
o(b) When procedures with status indicator codes C, N, or R, do not have RVUs assigned under the CMS’ National Physician
Fee Schedule Relative Value File, these services shall be reimbursed By Report.
Review of the operative report, services were performed and documented.
Opportunity for Claims Administrator to Dispute letter sent on 11/12/2015. A response from Claims Administrator was not
received for this review.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for the billed code 0232T-
RT and 0232T-LT.
20680 Reimbursement for CPT code
20680 was less than expected by the
Provider.
Reimbursement for CPT code 20680 was less than expected by the Provider.
Total billed charges for Hospital Outpatient Services = $11165.03.
This service has a status indicator of “T” and has the highest reimbursement rate of the services provided therefore
reimbursement is to be made at 100% of the allowable amount.
Provider’s conversion factor = 80.44959612.
Provider contract indicates at 5% reduction from OMFS amounts.
Hospital based outpatient surgical center reimbursement increased by 22%.
Based on the OPPS reimbursement set based on the following calculation:
20680 = 23.2928*80.44959612*1.22*.95= $2171.85

3. 20680 The Claims Administrator
denied service with the following
rational: “Service not paid under
OPPS.
Authorization signed by the Claims Administrator on 05/27/2015 indicates approval for “Hardware removal of left
elbow.”Operative note reflects services performed and not in conjunction with an Emergency Room Visit. CCR § 9789.33, For
services rendered on or after September 1, 2014, Status Indicators; “S”, “T”, “X”, or “V”, “Q1,”Q2,” or “Q3” must qualify for
separate payment.” must qualify for separate payment. APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). Based on the aforementioned documentation and guidelines,
reimbursement is indicated for 20680
20680-RT The Claims Administrator denied
service with the following rational:
“OP service status indicator Q. Q1
-Q3 payable only when not
packaged or bundled w/other
services billed on same day”
Provider seeking remuneration for 20680 Removal of Support Implant, Payment Status Indicator “Q2,” provided to Injured
Worker on 09/15/2015.
The Claims Administrator denied service with the following rational: “OP service status indicator Q. Q1
-Q3 payable only when not packaged or bundled w/other services billed on same day”
Authorization signed by the Claims Administrator on June 30, 2015 indicates approval for “Right ankle hardware removal.”
CCR § 9789.33, for services rendered on or after September 1, 2014, Status Indicators; “S”, “T”, “X”, or “V”, “Q1,” Q2 ,” or
“Q3” must qualify for separate payment .”
Provider billed code 20680 along with 73600 and 76000.
Operative note reflects services performed and not in conjunction with an Emergency Room Visit.
APC relative weight x adjusted conversion factor x 1.212 workers’ compensation multiplier, pursuant to Section 9789.30(aa).
Opportunity for Claims Administrator to Dispute sent 2/26/2016. A response from Claims Administrator was not received for
this review.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 20680

4. 23412 and 23120 Claims Administrator denied
services with“ Pre-authorization
required, reimbursement
denied.Visit limit has been reached”
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider is dissatisfied with reimbursement of codes 23412 and 23120 performed on date of service
11/18/2015.
Claims Administrator denied services with“ Pre-authorization required, reimbursement denied.Visit limit has been reached”
Utilization Review Determination of Appealed Request(s) dated 10/29/2015 documents: “specific description of the appealed
medical treatment service approved, if any:
(R) shoulder arthroscopic acromioplasty
Mumford
Rotator cuff repair
Physician’ s Operative Report documents right shoulder arthroscopic procedure converted to an open procedure
along with acromioplasty.
Title 8, California Code of Regulations Chapter 4.5, Division of Workers’ Compensation Subchapter 1 Administrative Director -
Administrative Rules Article 5.3 Official Medical Fee Schedule -Hospital Outpatient Departments and Ambulatory Surgical
Centers: Section 9789.33. Determination of Maximum Reasonable Fee Hospital Outpatient Department Services that are:
Surgical procedures; Emergency Room Visits; or services that are an integral part of the surgical procedure or emergency room
visit: For services rendered on or after September 1, 2014: APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative weight by date of service.
Opportunity for Claims Administrator to Dispute sent on 6/6/2016. A response was not
received for this review.
PPO contractual agreement not submitted for review.
Based on information and guidelines, reimbursement for codes 23412 and 23120 is warranted.

5. 24357-59 and 20610-
59
Claims Administrator denied codes
with indication “no separate
payment was made because the
value
of the service is included within the
value of another service performed
on the same day”
Provider seeking remuneration for codes 24357-59 and 20610-59 performed on 11/23/2015
Claims Administrator denied codes with indication “no separate payment was made because the value
of the service is included within the value of another service performed on the same day”
As pair codes exist between reimbursed code 64718/24357 and 24357/20610, modifier indicator column
shows ‘1’ which states that if an approved modifier is appended to the column ‘2’ code, and documentation is submitted to
support billed codes then the edit may be overridden.
Documentation submitted for review included Authorization for Shoulder Arthroscopy for Rotator
Cuff Synd NOS between dates 12/30/2015 and 01/30/2016. Also included was Provider ’s Operative Report for Procedure date
January 25, 2016.
Documentation to support date of service 11/23/2015 was not included with review.
Based on lack of documentation to support billed codes, reimbursement of 24357-59 and 20610
-59 is Upheld

6. 27425, 29877-59,
29874-59, 29875
-59, and 20610-59
Claims Administrator reimbursed
CPT code 29875 in the amount
$191.11 and denied all other
services billed.
Provider seeking reimbursement of codes 27425, 29877-59, 29874-59 and 20610-59 performed on date of service 02/01/2016.
Claims Administrator reimbursed CPT code 29875 in the amount $191.11 and denied all other services billed.
Submitted authorization dated December 23, 2015 verifies “Left knee lateral release has been CERTIFIED upon peer review
report”
Provider’s Operative Report submitted documents procedure performed:
1.Left knee arthroscopy, arthroscopic patellar chondroplasty
2.Arthroscopic synovectomy
3.Percutaneous lateral retinacular release
4.Injection Marcaine 25%, 20 ml, plus Toradol 30 mg.
Further in the Provider’s Operative Report states “Through a standard anterolateral portal, the Storz 5-
mmm, 30-degree arthroscope was inserted.” Under Operative Arthroscopy, Provider documents “a percutaneous lateral release
was then performed using Metzenbaum scissors. A 90-degree patellar tile test was possible post-release, and flexion-extension
tracking demonstrated centralization in the trochlea.”
Billed code 27425: Lateral retinacular release, open
Documentation does not support an “open” procedure was performed.
Parenthetical Guidelines specific to 27425: For arthroscopic lateral release, use 29873.
NCCI edits exist between procedure performed code 29873 and all other billed codes 29877, 29874, 29875 and 20610 which are
not separately reimbursable per Medicare correct coding guidelines.
Based on aforementioned documentation and guidelines, additional reimbursement is recommended for CPT 29873 only.
PPO contract not submitted for IBR

7. 29822-59,29826
-59
Provider is dissatisfied with denial of codes 29822-59 and 29826-59
Based on the NCCI edits, generally code 29824 and 29822 are generally not reported together either. However, Modifier
Indicator column shows ‘1’, there may be occasions where both codes are payable. Provider billed 29822-59, which is an
appropriate override modifier for the NCCI edit.
Based on review of the operative report, Provider documents 29822-59, Arthroscopy, shoulder, surgical; debridement, limited,
as a distinct procedure. Therefore, reimbursement for CPT 29822-59 is warranted.
CPT 29826-59 was also denied after having been approved by Claims Administrator’s Utilization Review as documented in the
Certification Recommendation letter received. CPTs approved in the letter from the Utilization Review include: 29826, 29827,
29807, 23430 and 29424. Claims Administrator approved 29826 prior to the procedure and then denied it as bundled with 23412
which was reimbursed. Since CPT 23412 was reimbursed, no reimbursement for 29826 is recommended.
PPO Contract reviewed shows a 6% discount is to be applied to the reimbursement.

8. 29824 The Claims Administrator denied
charges indicating: Initial EOR:
“We cannot review without the
necessary documentation...”Final
EOR: “Medical documentation does
not support the services rendered”
Provider seeking remuneration for 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface
(mumford procedure) for date of service 05/29/2015. SBR indicates a dispute amount of $2,220.96.
Opportunity to Dispute communicated to Claims Administrator on 01/28/2016 , response not yet received.
Operative Report, page 2, the Provider indicates, “distal 1cm clavicle was excised.”
Contractual Agreement not submitted for IBR; unknown if >1cm rem oval of clavicle is required for reimbursement. As the
size of the excised piece is not a CPT requirement, reimbursement is indicated
for 29824 and is subject to Endoscopic MPPR reimbursement.
§9789.16.5 (d)Determining Maximum Payment for Endoscopies (e) Multiple Procedures of Equal Value:
If two or more multiple surgeries are of equal value, rank them in descending dollar order billed and base payment on the
percentages listed above (i.e., 100 percent for the first billed procedure, 50 percent for the second, etc.)
EOR 07/09/2015 reflects $4,442.31 reimbursed for Primary Arthroscopic Procedure.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 29824

9. 29824 and 29822
-
59
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking remuneration of billed codes 29824 and 29822 erformed on date of service
12/07/2015.
Claims Administrator’s reimbursement rationale of CPT 29824 “H01: Priced according to state regs out-patient facility
schedule.” Claims Administrator denied 29822 with rationale “Service/item included in the value of other services per CCI
edits.”
Pair code does exist between the two codes with edit description: More extensive procedure.
29824 / 29822 -More extensive procedure
Per Medicare NCCI Policy Manual on More Extensive Procedures : The CPT Manual often describes groups of similar codes
differing in the complexity of the service. Unless services are performed at separate patient encounters or at separate anatomic
sites, the less complex service is included in the more complex service and is not separately
reportable.
29822: Arthroscopy, shoulder, surgical; debridement, limited
Per Medicare NCCI Policy Manual: E. Arthroscopy -With the exception of the knee joint, arthroscopic debridement should not
be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter.
Reimbursement of 29822 is not warranted.
PPO contract received states: “Outpatient Services percent discount. 10% Discount off of the rate or fee established by the
applicable Official Medical Fee Schedule of the applicable state provided to a Workers’ Compensation Claimant. 18% Discount
off usual billed charges for all other services. Notes: The reimbursement amounts will be the lesser of charges, the negotiated
rates or the applicable official Medical Fee Schedule rate or fee (when applicable to workers’compensation beneficiary), and as
mandated by the Hospital Official Medical Fee Schedule(s).”
Provider billed a total of $14,019.09 on a UB-04 with Bill Type 131, Hospital Outpatient.
Section 9789.33. Determination of Maximum Reasonable Fee: (a) In accordance with section 9789.32, the maximum allowable
payment for outpatient facility fees for hospital emergency room services, surgical services, or for Facility Only Services
performed at a hospital outpatient department, or for surgical services performed at an ambulatory surgical center shall be
determined based on the following:
For services rendered on or after September 1, 2014: APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative
weight by date of service.


10. 58.6059 x 83.44 x 1.212 = 5,926.77
x 90% = $5334.10

$14,019.09 x 82% = $11,495.65

Opportunity for Claims Administrator to Dispute sent on 6
/1/2016. A response from
Claims Administrator was not received for this review.

Based on Outpatient guidelines and contractual agreement, additional reimbursement is
due for code
29824
29824 and 29822-59 Claims Administrator’s
reimbursement rationale of CPT
29824 “H01: Priced according to
state regs out-patient facility
schedule.” Claims Administrator
denied 29822 with rationale
“Service/item included in the value
of other services per CCI edits.”
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking remuneration of billed codes 29824 and 29822 performed on date of
Service12/07/2015.
Claims Administrator’s reimbursement rationale of CPT 29824 “H01: Priced according to state regs out-patient facility
schedule.” Claims Administrator denied 29822 with rationale “Service/item included in the value of other services per CCI
edits.”
Pair code does exist between the two codes with edit description: More extensive procedure.
29824 / 29822 -More extensive procedure
Per Medicare NCCI Policy Manual on More Extensive Procedures: The CPT Manual often describes groups of similar codes
differing in the complexity of the service. Unless services are performed at separate patient encounters or at separate anatomic
sites, the less complex service is included in the more complex service and is not separately
reportable.
29822: Arthroscopy, shoulder, surgical; debridement, limited
Per Medicare NCCI Policy Manual: E. Arthroscopy -With the exception of the knee joint, arthroscopic debridement should not
be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter.
Reimbursement of 29822 is not warranted.
PPO contract received states: “Outpatient Services percent discount. 10% Discount off of the rate or fee established by the

11. applicable Official Medical Fee Schedule of the applicable state provided to a Workers’Compensation Claimant. 18% Discount
off usual billed charges for all other services. Notes: The reimbursement amounts will be the lesser of charges, the negotiated
rates or the applicable official Medical Fee Schedule rate or fee (when applicable to workers’compensation beneficiary), and as
mandated by the Hospital Official Medical Fee Schedule(s).”
Provider billed a total of $14,019.09 on a UB-04 with Bill Type 131, Hospital Outpatient.
Section 9789.33. Determination of Maximum Reasonable Fee: (a) In accordance with section 9789.32, the maximum allowable
payment for outpatient facility fees for hospital emergency room services, surgical services, or for Facility Only Services
performed at a hospital outpatient department, or for surgical services performed at an ambulatory surgical center shall be
determined based on the following:
For services rendered on or after September 1, 2014 : APC relative weight x adjusted conversion factor x 1.2
12 workers’ compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative
weight by date of service.

58.6059 x 83.44 x 1.212 = 5,926.77
x 90% = $5334.10
$14,019.09 x 82% = $11,495.65
Opportunity for Claims Administrator to Dispute sent on 6/1/2016. A response from Claims Administrator was not received for
this review.
Based on Outpatient guidelines and contractual agreement, additional reimbursement is due for code 29824.
29848-LT, 64718
-LT, 26055-LT, and
20550-59LT
Claims Administrator denied all
codes with rationale “diagnosis was
invalid for the date(s) of service
reported”
Provider seeking remuneration of billed codes 29848 -LT, 64718-LT, 26055-LT, and 20550-59LT
performed on date of service 12/02/2015
Claims Administrator denied all codes with rationale “diagnosis was invalid for the date(s) of service reported”
Authorization dated 11/12/2015 from Claims Administrator documents “The purpose of this letter is to confirm authorization for
the requested medical services noted below:
1.Wrist endoscopy/surgery 29848
2.Revise ulnar nerve at elbow 64718
3.Incise finger tendon sheath 26055
4.Physical Therapy Quantity: 8(2x4 left long finger)
5.Physical Therapy Quantity: 8 (2x4 left elbow)
6.Physical Therapy Quantity: 8 (2x4 left wrist)
*Documentation shows date range between 11/12/2015 and 1/11/2016.
*Diagnosis not documented on authorization.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health

12. and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Authorization dated 11/12/2015 is contract in nature.
Provider submitted Operative Report which documents services performed on the injured worker’s left wrist and left
finger.Report included diagnosis: Left carpal tunnel syndrome, left cubital tunnel syndrome, left long finger trigger digit and left
ring finger trigger digit.
Ambulatory Surgical Centers surgical procedures, for services rendered on or after September 1, 2014:
APC relative weight x adjusted conversion factor x 0.808 workers’ compensation multiplier, pursuant to Section 9789.30(aa).
Pursuant chapter 4 of the National Correct Coding Initiative Policy Manual for Medicare Services: Injections of local anesthesia
for musculoskeletal procedures (surgical or manipulative) are not separately reportable. For example, CPT codes 20526-
20553(therapeutic injection of carpal tunnel, tendon sheath, ligament, muscle trigger points) should not be reported for the
administration of local anesthesia to perform another procedure.
Reimbursement of 20550 is not warranted.
Opportunity for Claims Administrator to Dispute sent on 4/29/2016. A response was not received for this review.
Based on aforementioned documentation and guidelines, reimbursement of 29848, 64718 and 26055 is warranted.
29881-51 Claims Administrator denied code
indicating on the Explanation of
Review “No separate payment was
made because the value of the
service is included within the value
of another service performed on the
same date of service.”
Provider is dissatisfied with denial of code 29881-51.
Claims Administrator denied code indicating on the Explanation of Review “No separate payment was made because the value
of the service is included within the value of another service performed on the same date of service.”
Provider billed codes 29876 and 29881-51 on a CMS 1500 form.
Based on review ofthe operative report submitted, Provider documents very clear that a medical meniscectomy was performed
along with synovectomies of patellofemoral, medial and lateral compartments.
Claims Administrator was incorrect to deny code 29881-51. Therefore, reimbursement of code 29881 is warranted

13. 29882 Claims Administrator denied code
indicating “Allowance is based on
Utilization Review pre-
authorization”
Provider seeking remuneration for 29882 performed on date of service 10/15/2014
Claims Administrator denied code indicating “Allowance is based on Utilization Review pre-authorization”
Communication dated September 10, 2014 from Claims Administrator to Provider documents “
UR Decision: Approved: Left knee arthroscopy with partial medical meniscectomy, Qty: 1”
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Provider’s Operative Report documents Arthroscopic medial meniscal repair, right knee.
For services rendered on or after September 1, 2014: APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa).
EOR submitted shows a payment of $569.18 for 29882-LT.
Based on aforementioned guidelines and documentation, additional reimbursement of 29882 is warranted.
33249 and 93005 ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking additional remuneration for 33249 and 93005 performed on 12/03/2015.

14. Initial EOR does not provide a clear indication for“0.00” reimbursement .Services performed in addition to other services;
$359.07 out of $500,347.68 reimbursed.
Documentation indicates SBR requested; 2ndEOR not received.
CPT Status Indicator, Weight and AMA CPT Code Description:
CPT 33249: S,442.3292 , Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s),
single or dual chamber
CPT 93005: Q3, 0.3732, Electro cardiogram tracing, Electrocardiogram, routine ecg with at least 12 leads; tracing only,
without interpretation and report
Contractual Agreement not submitted for IBR.
CCR § 9789.33 , For services rendered on or after September 1, 2014, Status Indicators; “S”, “T”, “X”, or “V”, “Q1,” Q2,” or
“Q3 ” must qualify for separate payment.” must qualify for separate payment. APC relative weight x adjusted conversion factor x
1.212 workers’ compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative weight by
date of service
Based on the aforementioned documentation and guidelines, additional reimbursement
is indicated for
3
3249 and 93005.
63047-59-51 Claims Administrator was incorrect
to deny code 63047-59-51 and
therefore, reimbursement is
recommended.
Provider is dissatisfied with denial of CPT code 63047-59-51.
Based on the NCCI edits that exist with code 63047, Modifier Indicator is showing ‘1’ as a modifier appended can override the
NCCI Edit with supporting documentation. Modifier -59 is an accepting modifier for this rule per NCCI.
CPT 63047 -Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral
segment; lumbar
Based on review of the operative report page 2 paragraph two, Provider documents “dissection carried down bilaterally to
expose the inferior L3 lamina up the S1 lamina, and dissection was carried out laterally to the edges of the facets.”
Claims Administrator was incorrect to deny code 63047-59-51 and therefore, reimbursement is recommended.

15. A PPO discount of 5% will be applied as well as the multiple surgical procedures reimbursement Rule #7 Provider is dissatisfied
with denial of CPT code 63047-59-51.
Based on the NCCI edits that exist with code 63047, Modifier Indicator is showing ‘1’ as a modifier appended can override the
NCCI Edit with supporting documentation. Modifier -59 is an accepting modifier for this rule per NCCI.
CPT 63047 -Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral
segment; lumbar
Based on review of the operative report page 2 paragraph two, Provider documents “dissection carried down bilaterally to
expose the inferior L3 lamina up the S1 lamina, and dissection was carried out laterally to the edges of the facets.”
Claims Administrator was incorrect to deny code 63047-59-51 and therefore, reimbursement is recommended.
A PPO discount of 5% will be applied as well as the multiple surgical procedures reimbursement Rule #7
63650 and 63650
-59
EOR indicates DWC Payment
Reduction G1:“The charge exceeds
the Official Medical Fee Scheduled
Allowance.”
Provider seeking 100 % ASC remuneration for 63650 & 63650-59 for date of service 10/13/2015.
EOR indicates DWC Payment Reduction G1:“The charge exceeds the Official Medical Fee Scheduled Allowance.”
CMS 1500 reflects Bill Type “831.”
Contractual Agreement not submitted for IBR.
For services rendered on or after December 1, 2014, section 9789.30, subsections (a) adjusted conversion factor, (e) APC
payment rate, (f) APC relative weight, (j) Facility Only Services,(q) labor

16. -related share, (r) market basket inflation factor, and (z) wage index, are adjusted to conform to the
Medicare hospital outpatient prospective payment system (HOPPS) final rule of December 10, 2013, the
relative values in the 2014 Medicare Physician fee schedule, and the wage index values in the Medicare
IPPS final rule of August 19, 2013, and associated rules and notices to the IPPS final rule published
In the Federal Register.
For services rendered on or after September 1, 2014 APC relative weight x adjusted conversion factor
X 0.808 workers’ compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b)
For the APC relative weight by date of service.
63650 & 63650-59 are valid codes for date of service 10/13/2015 in accordance with theOMFS.
63650, Status Indicator “S,” not subject to MPPR.
Opportunity for Claims Administrator to Dispute Eligibility sent on 2/29/2016. A response from Claims
Administrator was not received for this review.
Based on the aforementioned documentation and guidelines, additional reimbursement for 63650 &
63650-59 is warranted
63661 x 3 Claims administrator denied codes
indicating on the Explanation of
Review “No separate payment was
made because the value of the
service is included within the value
of another service performed on the
same day””
Provider is dissatisfied with denial of codes 63661 x 3 units
Claims administrator denied codes indicating on the Explanation of Review “No separate payment was made because the value
of the service is included within the value of another service performed on the same day””
Operative Report received documents 1 electrode was removed on date of service 5/19/2015.
CCR § 9789.30, subsections (a) adjusted conversion factor, (e) APC payment rate, (f) APC relative weight, (j) Facility Only
Services, (q) labor-related share, (r) market basket inflation factor, and (z) wage index, are adjusted to conform to the Medicare
hospital outpatient prospective payment system (HOPPS) final rule of December 10, 2013, the relative values in the 2014
Medicare Physician fee schedule, and the wage index values in the Medicare IPPS final rule of August 19, 2013, and associated
rules and notices to the IPPS final rule published in the Federal Register.
Per CMS 2014 NCCI Edit Policy Manual: The MUE values for CPT code 63661 (removal of spinal neurostimulator electrode
percutaneous array(s)...) and CPT code 63662 (removal of spinal neurostimulator electrodeplate/paddle(s) placed via laminotomy
or laminectomy...) are one (1). Each code descriptor includes the removal of some or all electrode percutaneous arrays and some
or all electrode plates/paddles for a neurostimulator pulse generator. If a patient has two separate neurostimulator pulse
generators and some or all electrodes are removed for each neurostimulator pulse generator separately, the removal of the
percutaneous array(s) or plate(s)/paddle(s) for the second neurostimulator pulse generator may be reported with modifier 59.

17. Based on aforementioned guidelines, reimbursement of one (1) unit of 63661 is warranted.
63685 and 76000
-
59
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking additional reimbursement for codes 63685 & 76000 -59 per formed on date
of service 02/16/2016.
The Provider billed the disputed codes on a UB04, with bill type 131, Outpatient services.
Claims Administrator based reimbursement with “Workers Compensation Jurisdictional Fee Schedule Adjustment”
A PPO Contractual agreement not submitted for reviewed.
76000: Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time, other than
71023 or 71034 (eg, cardiac fluoroscopy)
NCCI Policy Manual for Medicare Service: Separate Procedure: If a CPT code descriptor includes the term “separate
procedure”, the CPT code may not be reported separately with a related procedure. CMS interprets this designation to prohibit the
separate reporting of a “separate procedure” when performed with another procedure in
an anatomically related region often through the same skin incision, orifice, or surgical approach.
A CPT code with the “separate procedure” designation may be reported with another procedure if it is performed at a separate
patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area often through a
separate skin incision, orifice, or surgical approach.
20. Fluoroscopy reported as CPT codes 76000 or 76001 should not be reported with spinal procedures unless there is a specific
CPT Manual instruction indicating that it is separately reportable. For some spinal procedures there are specific radiologic
guidance codes to report in lieu of these fluoroscopy codes. For other spinal procedures,
fluoroscopy is used in lieu of a more traditional intraoperative radiologic examination which is included in the operative
procedure. For other spinal procedure codes, fluoroscopy is integral to the procedure.
Documentation submitted does not reflect a “separate procedure”
Reimbursement of 76000-59 is not warranted.
§9789.33 - For services rendered on or after September 1, 2014; APC relative weight x adjusted conversion factor x 1.212
workers’compensation multiplier, pursuant to Section 9789.30(aa).
63685: 237.1326 x $83.31 x 1.212 = $23,943.69

18. CPT 63685 has a status code “S” procedures.
“S” Procedure or Service, Not Discounted When Multiple . Paid under OPPS; separate APC payment.
Additional reimbursement is warranted for the CPT code 63685

19. 64483- LT Claims Administrator denied codes
indicating on the Explanation of
Review “Service/item included in
the value of other services per CCI
edits. Related service could be on a
separate bill .” EORs submitted
show only two codes billed, 64483
and 72275.
Notice of Authorization dated August 17, 2015 from Claims Administrator certified “Left L4 Transforaminal
Epidural Steroid Injection, anesthesia, under fluoroscopic guidance at Galileo Surgery Center. ”
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Documentation dated August 17, 2015 is contract in nature.
Provider billed code 64483 along with 72275 on a CMS 1500 with place of service 24.
Provider’s Operative Procedure Report documents Left L4 Transforaminal Epidural Steroid Injection under Fluoroscopy.
Based on guidelines and documentation reviewed, reimbursement of 64483-LT is warranted.
64493 and 64495 Provider is seeking remuneration of code 64493 -50 performed on date of service 02/11/2016. 64495 is not in dispute.
Claims administrator reimbursed denied service indicating on the Explanation of Review “charge is denied as the service was
not authorized”
Communication from Claims Administrator dated January 19, 2016 documents “I am authorizing the request for medical branch
block to test bilateral L4-5 and L5-S1 facet joints. ” Specific date or date range not documented on authorization.
For services rendered on or after September 1, 2014: APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative weight by date of service.
Provider’s Operative Report documents bilateral injections and submitted code 64493 with a modifier
-50. Modifier -50 supports the bilateral procedure and is reimbursed an increase of 150% of the fee schedule of a single code.
9.2183 x 87.33 x 1.21 = 974.09 x 150% = 1461.14 x 93% = $1358.86
Opportunity to Dispute Letter was sent to Claims Administrator on 5/18/2016. A response from Claims Administrator was not

20. received for this review. Based on information reviewed, additional reimbursement is warranted for code 64493-50.
PPO contract submitted shows a 7% PPO discount is to be applied to reimburse
64493 and 64495 Claims administrator reimbursed
denied service indicating on the
Explanation of Review “charge is
denied as the service was not
authorized”
Provider is seeking remuneration of code64493-50 performed on date of service 02/11/2016.
64495 is not in dispute.
Claims administrator reimbursed denied service indicating on the Explanation of Review “charge is denied as the service was
not authorized”
Communication from Claims Administrator dated January 19, 2016 documents “I am authorizing the r
equest for medical branch block to test bilateral L4-5and L5-S1 facet joints.” Specific date or date range not documented on
authorization.
For services rendered on or after September 1, 2014: APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative weight by date of service.
Provider’s Operative Report documents bilateral injections and submitted code 64493 with a modifier
-50. Modifier -50 supports the bilateral procedure and is reimbursed an increase of 150% of the fee schedule of a single code.
9.2183 x 87.33 x 1.21 = 974.09 x 150% = 1461.14 x 93% = $1358.86
Opportunity to Dispute Letter was sent to Claims Administrator on 5/18/2016. A response from Claims Administrator was not
received for this review.
Based on information reviewed, additional reimbursement is warranted for code 64493-50.
PPO contract submitted shows a 7% PPO discount is to be applied to reimbursement

21. 64510 Claims Administrator denied
service indicating on the
Explanation of Review “ This
service appears to be unrelated to
the patients diagnosis”
Provider billed diagnosis G90.511 on UB-04 with bill type 837.
G90.511: Complex regional pain syndrome of right upper limb.
Provider’s Operative Report documents “Stellate Ganglion Block “fluoroscopy was used to identify the right C-6transverse
process” and “spinal needle was advanced toward the medial aspect of the C-6 transverse process...”
RFA dated 08-28-2015 documents “Procedure Requested: Stellate Ganglion Block on the Right Side under Fluoroscopy and
monitored anesthesia care to be done at Oasis Surgery Center”
Communication from Claims Administrator to Provider dated September 25, 2015 showing authorization for “Approved Service
Description: Right Stellate Ganglion Block under Fluoroscopy and monitored anesthesia care”
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Communication from Claims Administrator dated September 25, 2015 is contract in nature.
Based on information reviewed and guidelines, reimbursement of 64510 is warranted.
64520 Claims Administrator denied code
with rationale “revenue codes and
other packaged procedures are not
separately
Reimbursable and are to be
packaged into other services when
billed on an outpatient basis”
Provider seeking remuneration of 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic performed on
date of service 08/03/2015
Claims Administrator denied code with rationale “revenue codes and other packaged procedures are not separately
Reimbursable and are to be packaged into other services when billed on an outpatient basis”
64520 has status indicator T -Procedure, Multiple Reduction Applies. Paid under OPPS; Separate APC payment.
Status Code Indicators: For services rendered on or after September 1, 2014-“S”, “T”, “X”, or “V”, “Q1”, Q2”, or “Q3”. Status

22. code indicators “Q1”, “Q2”, and “Q3” must qualify for separate payment.
Provider billed code 64520 along with J8499, J2250 and J3010 on a UB04 Type of Bill 131.
Authorization submitted documents “Left lumbar Paravertebral Sympathetic Block with IV Sedation; medically necessary”
dated July 13, 2015.
Final Report submitted documents Left lumbar paravertebral sympathetic block performed on date of service 8/3/2015.
For services rendered on or after September 1, 2014 : APC relative weight x adjusted conversion factor x 1.212 workers’
compensation multiplier, pursuant to Section 9789.30(aa). See Section 9789.39(b) for the APC relative.
Based on documentation and guidelines, reimbursement of 64520 is warranted
64718-59 Claims Administrator denied code
indicating “no separate payment
was made because the value of the
service is included within the value
of another service performed on the
same day”
Provider billed code 64718-59 along with 25115 which was reimbursed.
As a pair code edit does exist with codes 64718 and 25115, modifier indicator column shows a ‘1’ which states that if an
approved modifier is appended to the column 2 code, and documentation supports billed code, then the edit may be overridden.
Provider appended approved modifier -59 to column 2 code 64718
Provider’s Operative Report supports 64718 with modifier -59, a separate incision/excision was made.
Based on documentation and guidelines, reimbursement of 64718-59 is warranted.
64721
-
59
,
RT
ANALYSIS AND FINDING
Based on review of the case file the followi
ng is noted:

ISSUE IN DISPUTE
:
P
rovider seeking remuneration for 64721
-
59

23. -
RT services
submitted for date of service 11/1
9/2015.

E
OR
’
s indicate s
ervices denied per NCCI edits.

Opportunity to Dispute
c
ommunicated with the Claims Administrator on 06/08/2016:
response not yet
received
.

Contractual Agreement not
submitted
for IBR.

A
uthorization signed by the Claims Administrator reflects anatomical sites
r
elating to right
hand and right elbow.

Services billed utilizing CMS 1500.

NCCI edits indicate CPT 64721 is a column
2 code to (billed
services
) 64708.

AMA CPT indicates
“
Modifier 59 is used to identify procedures/services, other than E/M
services, that are not normally reported to
gether, but are appropriate under the circumstances.
Documentation must support a different session, different procedure or surgery,
different
site
or organ system, separate incision/excision, separate lesion, or separate injury (or area of

24. injury in exte
nsive injuries) not ordinarily encountered or performed on the same day by the
same individual.
”
(
Emphasis
a
dded)

Operative report
r
eflects 64721
and 64708 procedures were
performed
on different
anatomical sites;
right
wrist
median nerve
,
right
elbow
interosseous nerve branch of the
rad
ial nerve.

CMS 1500
appropriately
reflects modifier
-
59.

64721
Physician Fee Schedule Relative Value File refle
cts service is subject to MPPR and
will be reflected in the
reimbursement
table on page 4.

B
ased on the
aforementioned
documentation and
guidelines

25. ,
reimbursement
is
indicated for 64721.
72070 and
72110
Claims administrator denied codes
indicating on the Explanation of
Review “The charge was denied as
the report/documentation does not
indicate that the procedure was
performed.”
Provider is dissatisfied with denial of codes 72070 and 72110
Claims administrator denied codes indicating on the Explanation of Review “The charge was denied as the
report/documentation does not indicate that the procedure was performed.”
Provider documents in the report submitted that the worker was injured when a co-worker fell on top of her and she landed on
her back and neck areas. Also noted in the report, medical necessity: lumbar spine 5 views –standard claim of pain LS area;
thoracic spine 2 views claim of pain T spine area. Both with Findings ‘pending’. Diagnoses: contusion –back lower (922.31);
contusion –back upper (922.33)
Based on information reviewed, Provider does document procedures were performed during the new patient exam and therefore,
reimbursement of codes 72070 and 72110 is warranted.

26. 72070 and 72110 ISSUE IN DISPUTE:
Provider is dissatisfied with denial of codes 72070 and 72110
Claims administrator denied codes indicating on the Explanation of Review “The charge was denied as the
report/documentation does not indicate that the procedure was performed.”
Provider documents in the report submitted that the worker was injured when a co-worker
fell on top of her and she landed on her back and neck areas. Also noted in the report, medical necessity: lumbar spine 5 views –
standard claim of pain LS area; thoracic spine 2 views claim of pain T spine area.
Both with Findings ‘pending’. Diagnoses: contusion –back lower (922.31); contusion –back upper (922.33)
Based on information reviewed, Provider does document procedures were performed during the new patient exam and
therefore, reimbursement of codes 72070 and 72110 is warranted.
72275-26-59 Claims Administrator denied code
indicating on the Explanation of
Provider is dissatisfied with denial of code 72275-26-59
Claims Administrator denied code indicating on the Explanation of Review “The appended modifier code is not appropriate

27. Review “The appended modifier
code is not appropriate with the
service billed”
with the service billed”
72275 -Epidurography, radiological supervision and interpretation
Authorization received dated 03/18/2015 states “Cervical Epidural Steroid Injection under Anesthesia with X-ray and
Fluoroscopic Guidance is medically approved by the utilization review nurse”
CPT Guidelines state “Fluoroscopy (for localization) may be used in the placement of injections reported with 62310-62319,
but is not required. If used, fluoroscopy should be reported with 77003. For epidurography, use 72275”
Provider submitted an Operative Report along with a separate Epidurogram report which is required for code 72275.
Based on UR authorization and CPT guidelines, reimbursement of 72275 is warranted.
PPO contract received shows a 15% discount is to be applied to reimbursement
73721 The Claims Administrator denied
service as unauthorized.
Provider seeking remuneration for 73721 MRI joint of l0wr extremity w/o dye performed on 05/06/2015.
The Claims Administrator denied service as unauthorized.
Submitted Contractual Agreement, “Appendix A/B” reflects “95%” OMFS.
Authorization, dated “April 27, 2015,” signed by Claims Administrator states the following service and CPT Code
as “medically necessary” :o MRI Left Hip 73721
CCR § 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for
reimbursement rates different from those in the fee schedule , the medical fee schedule for that health care provider or health
facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
The aforementioned ‘April 27, 2015,” documentation is contractual in nature. As such, the contractual agreement applies
pursuant to LC § 5307.11 and reimbursement is warranted.

28. 76942 The Claims Administrator denied
reimbursement for 76942 stating:
“Incidental to Procedure,” and
“rarely, if ever, performed.”
Provider seeking remuneration for 76942 Ultrasonic guidance utilized for Pain Pump Refill needle placement (eg, biopsy,
aspiration, injection, localization device), imaging supervision and interpretation services performed on 04/22/2015 &
05/27/2015.
The Claims Administrator denied reimbursement for 76942 stating: “Incidental to Procedure,” and “rarely, if ever, performed.”
Included for IBR is a dictated Secondary Physician Progress Report.
CPT 76942 code description includes “imaging supervision and interpretation.”
A Secondary Physician Progress Report reflecting dates of service 04/22/2015 and 05/27/2015 reviewed , indicating Ultrasonic
Guidance was necessary due to “hypermobility of pump.”
Three 3 x 4 inch print images (copies) of the ultrasounds were reviewed reflecting dates of service 04/22/2015 and 05/27/2015.
Medicare Regulations Revision. 2932, 04-18-14, Chapter 13, section 20.1 for “Professional Component” (PC) states: “The
interpretation of a diagnostic procedure includes a written report.”
A separate copy of the Ultrasonic interpretation was included and reviewed reflecting dates of service 04/22/2015 and
05/27/2015.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 76942.
90792 Claims Administrator denied code
indicating “The charge was denied
as the report/documentation does
Provider seeking remuneration for 90792, Psychiatric diagnostic evaluation with medical services for date of service 06/24/2015
Claims Administrator denied code indicating “The charge was denied as the report/documentation does
not indicate that the service was performed”

29. not indicate that the service was
performed”
Beginning in 2013, there are two new codes to use to report psychiatric diagnostic procedures: 90791 for evaluations that do not
include medical services, and code 90792 for evaluations that do include medical services. "Medical services" consist of medical
activities or consideration, such as performing additional elements of the physical examination, considering writing a
prescription, ordering laboratory or imaging
examination(s), and considering modifying psychiatric treatment based on medical comorbidities.
Documentation submitted for review supports billed code 90792.
Reimbursement of 90792 is warranted.
PPO contract not submitted for review.
EOR received reflects a 5% PPO discount to be applied to reimbursement.
90792,
Psychiatric diagnostic
evaluation
Claims Administrator denied code
indicating “The charge was denied
as the report/documentation does
not indicate that the service was
performed
Provider seeking remuneration for 90792, Psychiatric diagnostic evaluation with medical services for date of service
06/24/2015
Claims Administrator denied code indicating “The charge was denied as the report/documentation does not indicate that the
service was performed”
Beginning in 2013, there are two new codes to use to report psychiatric diagnostic procedures: 90791 for evaluations that do not
include medical services, and code 90792 for evaluations that do include medical services. "Medical services" consist of medical
activities or consideration, such as performing additional elements of the physical examination, considering writing a
prescription, ordering laboratory or imaging examination(s), and considering modifying psychiatric treatment based on medical
comorbidities.
Documentation submitted for review supports billed code 90792.
Reimbursement of 90792 is warranted.
PPO contract not submitted for review.
EOR received reflects a 5% PPO discount to be applied to reimbursement.

30. 90833 Claims Administrator denied code
indicating on the Explanation of
Review “Documentation does not
support prolonged services.”
Provider is dissatisfied with denial of CPT 90833.
Claims Administrator denied code indicating on the Explanation of Review “Documentation does not support prolonged
services.”
Provider’s Progress Report (PR-2) submitted documents 90833 (including 20 minutes of psychotherapy)
Based on CPT Guidelines 2014, in reporting psychotherapy codes, choose the code closest to the actual time (ie, 16-37 minutes
for 90832 and 90833).
90833 –Psychotherapy, 30 minutes with patient and/or family member when performed with an valuation and management
service. (list separately in addition to the code for primary procedure). Use 90833 in conjunction with 99201-99255
Explanation of Review shows a 5% discount was applied to reimbursement. A 5% discount shall
be applied.
90837 Claims Administrator denied code
indicating on the Explanation of
Review “CPT code submitted is
based on service time and
documentation does not support the
time spent on this procedure”
Provider is dissatisfied with denial of code 90837
Claims Administrator denied code indicating on the Explanation of Review “CPT code submitted is based on service time and
documentation does not support the time spent on this procedure”
90837 -Psychotherapy, 60 minutes with patient and/or family member
Psychiatric PTP Progress Report and Chart Note submitted states “60 min face to face”for code 90837.
EOR received from Claims Administrator shows a payment was submitted to Provider in the amount $142.97for code 90837
after this dispute had been filed.
Based on information reviewed, reimbursed was warranted for code 90837 and therefore, Claims Administrator is responsible

31. for the IBR application fee in the amount of $195.00
90837 Claims Administrator denied code
indicating on the Explanation of
Review “CPT code submitted is
based on service time and
documentation does not support the
time spent on this procedure”
”
Final EOR submitted states two dates of service reviewed: 5/18/2015 and 6/2/2015. Per CCR, title 8 section 9792.5.8, Provider
is to submit final EOR submitting second review of codes billed.
Claims Administrator denied code indicating on the Explanation of Review “CPT code submitted is based on service time and
documentation does not support the time spent on this procedure”
Claims Administrator denied 90837 on both dates of service as “charge exceeds the Official Medical Fee Schedule”
UR Determination dated May 06, 2015 authorized 6 psychotherapy treatments between 4/20/2015 and 7/3/2015.
Specific CPT codes 90837 and 96101 submitted on RFA.
Based on information reviewed, reimbursement is warranted for code 90837 on both dates of service.
EOR submitted shows a 5% PPO discount to be applied to reimbursement
90837 x 4 units Claims Administrator denied 90837
service stating: “Per CCI Edits, the
value of this procedure is included
in the value of the comprehensive
Provider seeking remuneration 90837 Psychotherapy, 60 minutes x 4 units for dates of service: 02/20/2014, 03/16/2014,
03/20/2014 and 04/03/2014.
Claims Administrator denied 90837 service stating: “Per CCI Edits, the value of this procedure is included in the value of the
comprehensive procedure.”

32. procedure.” 90837, is paired to billed code 90901, biofeedback training by any modality.
NCCI edits reveal 90901 is Colum 1 Code when billed with Colum 2 Code, 90901.
Under certain circumstances, the paired codes in question may be unbundled with the use of modifier
-59. NCCI Edits state,“Modifier 59: Modifier 59 is an important NCCI-associated modifier that is often used incorrectly. For the
NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient
encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more
procedure codes. The CPT Manual defines modifier 59 as follows: Modifier 59: ‘Distinct Procedural Service: Under certain
circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M
services performed on the same day. Modifier 59 is used to identify procedures/services other than E/M services that are not
normally reported together, but are appropriate under the circumstances. Documentation must support a different session,
different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or
area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However,
when another already established modifier is appropriate, it should be used rather than modifier 59.’ ”
Documentation of 02/20/2014, 03/16/2014, 03/20/2014 and 04/03/2014. Patient encounters included
one PR-2 report listing the dates in question. Documentation indicates “time spent in session 60 min,” for all four listed dates.
Separately Identifiable service, over and above 90837 60 min service could not be identified.
Claims Administrator Reimbursed Provider for 90901 on all dates of service.
Only 90837 services are clearly identified in documentation.
Based on the aforementioned guidelines, reimbursement is recommended for 4units of 90837.
Contractual Agreement requested on 09/24/2013 not yet received during IBR. As such, reimbursement rate could not be
identified. OMFS will be utilized to calculate reimbursement.
EOR reflects Provider Reimbursed 4 units of 90901 @ $58.24= $232.96
Authorization for services dated February 25, 2014 states “Cognitive Behavioral Sessions,” and Biofeedback Therapy Sessions,”
X6 as “Certified.”
Recommend reimbursement for 90876, “Individual psychophysiological therapy incorporating biofeedback training by any
modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, behavior modifying or supportive
psychotherapy); 45 minutes,” as code best describes authorized se

33. 90880 The Claims Administrator denied
services indicating “resubmit with
indicated documentation as soon as
possible.”
Provider seeking remuneration for 90880 Hypnotherapy services submitted for dates of service 09/30/2015-10/28/2015.
The Claims Administrator denied services indicating “resubmit with indicated documentation as soon as possible.”
Authorization dated August 20, 2015 “Approved” 90880 for 1session a week x 8 weeks between 08/13/215-12/30/15 and
signed by Claims Administrator.
Provider billed code 90880 on the same dates of service as 90853.
Documentation of 90880 services reflected on Psychological Assessment Services “progress notes” documents “Procedure
codes 90880 & 90853 were provided on the same day but not in conjunction during the same session.”
NCCI Edit pair code exists between billed codes 90880 and 90853. Modifier Indicator column shows ‘0’which states a modifier
is not appropriate and services represented by code combination not paid separately
Based on the aforementioned documentation, authorized services for 90880 is not indicated
.
95886 and 95913 Claims Administrator denied
reimbursement indicating “charge is
denied as the service was not
Authorized during the Utilization
Review process
.
Communication to Provider from Claims Administrator dated November 10, 2015 documents “Approved Service Description:
EMG Left Upper Extremity, NCV Left Upper Extremity, EMG Right Upper Extremity” between date of service 11/03/15-
02/29/2016.
Not approved by Utilization Review NCV Right Upper Extremity.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Documentation dated November 10, 2015 is contract in nature and therefore services were approved.
Provider submitted documentation supporting nerve and muscle tests conducted on date of
service 12/2/2015

34. 95913 ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking additional remuneration for 95913, 13 or more Nerve Conduction Studies,
submitted for date of service 09/24/2014.
Opportunity to Dispute Eligibility communicated with the Claims Administrator on 04/13/2016; response received
04/26/2016. The Claims Administrator indicated the Left Median Sensory and Left Median Radial is “not related to the work
comp injury of the right upper extremity,” and the left hand comparison studies were “ not counted.”
Referral, Signed by the QME on 09/09/2014, indicates Right Upper Extremity EMG/NCV.
Nerve Conduction Study Results indicate the following sensory nerves tested on the Right Upper Extremities:1.Ulnar Nerve –
Right
To 5th
digit
Dorsal Cutaneous 2. Median Nerve –Right
Left Median not authorized 3.RadialNerve –Right
Total Sensory Nerves = 3
Nerve Conduction Study Results indicate the following motor nerves tested on the upper extremities: 1.Radial Motor -Right2.
Median Motor –Right 3. Ulnar Motor –Right
Total Motor Nerves Tested = 3
Documentation for Nerve Conduction Study reflects 6 nerves studied
 Provider’s Consultation Report indicates “peak latency differencesn” were “noted on comparison” resulting
in a diagnosis of “ carpel tunnel syndrome based on the comparison studies.”Reimbursement is indicated for the comparison
studies 5 Studies, R. Median, Ulnar and bilaterally.
Based on the aforementioned documentation and the review of the CPT descriptor, CPT code Reimbursement
is recommend for 95912, Nerve conduction test 11-12 studies,
and is not
indicated for 95913.

35. 95913 Claims Administrator denied code
with indication “The testing results
are needed in order to review this
charge”
Claims Administrator denied code with indication “The testing results are needed in order to review this charge”
Submitted for review was the Lower Extremity Study Electrodiagnostic Examination Report showing results for
12 sensory and motor nerves tested.
CPT Assistant for 95913 -A nerve conduction study is counted only once when multiple sites on the same nerve are stimulated
or recorded. Motor, sensory, mixed motor/sensory, or H-reflex tests are each counted per nerve tested.
Letter dated March 30, 2015 shows Utilization Review Determination & Authorization for EMG/NCV Bilateral Lower
Extremities, Begin Date: 3/26/2015, Expiration Date: 5/10/2015. Letter also states “
The treatment noted above has been determined to be medically necessary”
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Authorization dated March 30, 2015 is contract in nature. Therefore, reimbursement for 95912 is warranted.
95913 and 95937 EOR’s indicate service 95913
down-coded to reflect “contract
rate.”
Contractual Agreement not submitted for review; EOR indicates PPO reduction of 85% OMFS.
Referral with request for EMG/NCV and Neurodiagnostic Testing for left upper extremities identified in review.
AMA CPT Code Description: 95913 Nerve Conduction studies; 13 or more

36. Documentation includes dictated evaluation report and computerized results of studies. Data and Interpreted Report indicate
service 95913, specifically 13 nerve studies performed on the left upper extremities.
CPT 95937 denied by the Claims Administrator due to “service is for a condition which is not related to the covered work
related injury.”
95937 AMA CPT Assist: 95937 CPT Code 95937 -Neuromuscular Junction Studies
Repetitive stimulation studies are used to identify and to differentiate disorders of the NMJ. This test consists of recording
muscle responses to a series of nerve stimulus (at variable rates), both before, and at various intervals after, exercise or
transmission of high-frequency stimuli.
These codes may be used in association with motor and sensory NCSs of the same nerves and are reimbursed separately.
When this study is performed, the physician's report should note characteristics of the test, including the rate of repetition of
stimulations, and any significant incremental or decremental response.
95937 Report can be found on page 4 of the submitted documentation.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for CPT 95913 and 95937.
95937 Claims Administrator denied code
indicating on the Explanation of
Review “This service appears to be
unrelated to the patient’s diagnosis”
Provider is dissatisfied with denial of code 95937, Neuromuscular junction testing (repetitive stimulation, paired stimuli), each
nerve, any 1 method
Claims Administrator denied code indicating on the Explanation of Review “This service appears to be unrelated to the patient’s
diagnosis”
Referral from AME to Provider requesting EMG bilateral upper extremities R/O radiculopathy was identified for this review.
Computerized test results along with narrative interpretation of findings was submitted for review.
Based on information reviewed, reimbursement of 95937 is warranted.

37. 95937 Claims Administrator denied code
95937 indicating on the Explanation
of Review “code 95937 is reported
once per each nerve. Code 95937
cannot be reported for bilateral
(modifier 50) studies.
Provider seeking remuneration of code 95937 performed on 8/6/2015.
Claims Administrator denied code 95937 indicating on the Explanation of Review “code 95937 is reported once per each nerve.
Code 95937 cannot be reported for bilateral (modifier 50) studies. The nerve studied was the ABD Hallucis.” Provider did not
bill 95937 with modifier -50, bilateral.
Referral to QME requesting EMG/NCV and Neurodiagnostic Testing for bilateral lower extremities identified in review.
95937: Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.
AMA CPT Assistant: To demonstrate and characterize abnormal neuromuscular transmission, repetitive nerve stimulation
studies should be performed in up to two nerves and SFEMG in up to two muscles.
Provide r documented NCV testing and computerized findings in submitted report for date of service 8/6/2015.
Report documents computerized results of two units, one right and one left abductor Hallucis.
Reimbursement is warranted for 95937x 2units
96101 The Claims Administrator’s based
reimbursement on the following
rational:“ applicable fee schedule.”
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking full remuneration for 96101 services performed on 04/27/2015.
The Claims Administrator’s based reimbursement on the following rational:“ applicable fee schedule.”
Med-Legal services not in dispute; units of 96100 is disputed by the Claims Administrator; EOR reflects 5 of 7 submitted units
reimbursed.
§ 9794 Reimbursement of Medical-Legal Expenses.
(a) The cost of comprehensive, follow-up and supplemental medical-legal evaluation reports, diagnostic tests, and medical-legal

38. testimony, regardless of whether incurred on behalf of the employee or claims administrator, shall be billed and reimbursed as
follows:
(1) X-rays, laboratory services and other diagnostic tests shall be billed and reimbursed in accordance with the official medical
fee schedule adopted pursuant to Labor Code Section 5307.1. In no event shall the claims administrator be liable for the cost of
any diagnostic test provided in connection with a comprehensive medical-legal evaluation report unless the subjective complaints
and physical findings that
warrant the necessity for the test are included in the medical-legal evaluation report. Additionally, the claims administrator shall
not be liable for the cost of diagnostic tests, absent prior authorization by the claims administrator, if adequate medical
information is already in the medical record provided to the physician.
Psychological Report, Page 17, the following time factors associated with each psychological exam are noted:
MMPI-2 = 1.5 hours
MCMI-III = 1.5 hours
Sentence Completion Test = .5 hours
Whaler Physical Symptom Inventory = .5 hours
Beck Depression Scale = 1 hr
Beck Anxiety Scale = 1 hr
Work Function Impairment Form Questionnaire = 1 hr
Total Hours = 7
Based on the aforementioned documentation and guidelines, additional reimbursement
is indicated for 96101 pursuant to § 9794.
96101-
59, 96102, 90899, and
ANALYSIS AND FINDING
Based on review of the case file the following is noted:

39. WC
007 96101 -59, 96102,
90899, and WC007
ISSUE IN DISPUTE
Provider seeking additional remuneration for 96101-59, 96102, 90899, and WC 007 ervices performed
10/13/2015.
The Claims Administrator denied codes with rationale “
Communication from Legal Parties authorizing Med-Legal services reviewed.
Code Description CPT 96101 Psychological; testing (includes psychodiagnostic assessment of emotionality, intellectual
abilities, personality and psychopathology, e.g., mmpi, rorschach, wais), per hour of the psychologist's or physician's time, both
face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.
96102: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by
technician, per hour of technician time, face-to-face.
Page 1 of the Provider’s Psychological Consultation Report documents “6 hours of Psychological test completion and
interpretation by a psychologist ; 96102 -59 for 1 additional hour of test assessment and scoring by a psychologist”
Per Correct Coding Policies for NCCI Policy Manual for Medicare Services, 1/1/2015 chapter 1 Mutually Exclusive
Procedures-Many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually
exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter.
CPT codes 96101 and 96102 are mutually exclusive of each other and cannot be reimbursed separately. Therefore,
reimbursement of 96102 is not warranted.
A pair code does exist between reimbursed code 99205 and 96101, however, modifier indicator column shows ‘1’ stating that if
an approved modifier is appended to the column ‘2’ code, and documentation supports billed code, then the edit may be
overridden.
Column ‘2’code 96101 has approved modifier -59 appended and documentation does support billed code. Reimbursement of
96101 is warranted.
Request for Authorization shows “Service/Good Requested: Psych Consultation, Extended Time, Testing Interpretation by
Tech., Psychological Testing and Report; CPT/HCPCS code: 99205, 99354, 96102, 96101 and WC007” and is signed and dated
10/9/15 by Claims Administrator
showing “Approved”
Based on aforementioned guidelines and documentation, additional reimbursement of 96101 and WC007 is warranted

40. 96101 and WC007 Claims Administrator denied 96101
with rationale “Per CCI edits, the
value of this procedure is included
in the value of the comprehensive
procedure”
Provider is dissatisfied with denial of codes WC007-30 and 96101-59, Psychological testing (includes psychodiagnostic
assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of
the psychologist's or physician's time, both face-to-face time administering
tests to the patient and time interpreting these test results and preparing the report.
Claims Administrator denied WC007-30 with rationale “This report does not fall under the guidelines for a separately
reimbursable report found in the General Instructions Section of the Physician’s Fee Schedule”
Modifier -30 states: 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.
A request for Provider to submit a report was not identified in this review. Therefore, reimbursement of WC007 is not
warranted.
Claims Administrator denied 96101 with rationale “Per CCI edits, the value of this procedure is included in the value of the
comprehensive procedure”
Provider billed code 96101 with modifier -59 which is an approved modifier to append to the column ‘2’code.
Psychological Testing Report submitted documents 9.5 hours of time involved for application, scoring and interpretation.
Based on information reviewed and guidelines, reimbursement of 96101 is warranted
96101 x 7 ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking full remuneration for Psychological Testing 96101 Per Hour s
services performed on 08/29/2014 as part of a Medical Legal Evaluation.
The Claims Administrator denied the service indicating: “Workman’s Compensation Fee Schedule Adjustment. The Amount
adjusted is due to bundling or unbundling of service.”
Unless otherwise agreed upon by Claims Administrator and Provider, National Correct Coding Initiative do not apply to
Medical Legal claims.
Contractual Agreement regarding capitation relating to 96101 service as part of a Medical Legal Exam
not indicated on 07/25/2014 correspondence to Provider, the “Agreed Medical Evaluator in the field of psychiatry.”
07/25/14 Communication to AME from Legal Parties directs the AME to “examine the applicant, perform any non-invasive
testing that you deem reasonable and necessary...”
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h) "Medical-legal expense" means
any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the appeals board for X-
rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and as needed, interpreter's

41. fees, for the purpose of proving
or disproving a contested claim.
CPT 96101: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, mmpi, rorschach, wais), per hour of the psychologist's or physician's time, both face-to-face time
administering tests to the patient and time interpreting these test results and preparing the report
EOR Reflects ML104 Evaluation accepted and reimbursed by Claims Administrator.
EOR Reflects 96101 Psychological Testing reimbursed for 5 Units.
AME Evaluation, page 11, under “Psychological Testing,” Paragraph three (3), the AME documents a total of 7 total hours
spent on various psychological testing. The table below describes the pertinent claim line information
96101-59 and 99354 The Claims Administrator denied
charges as “included” in the value
of other services performed on the
same day.
96101-59 Psychological Testing and 99354 Face-to-Face Per Hour Prolonged Services performed on 11/30/2015.
Authorization dated “September 20, 2015,” signed by the Claims Administrator indicates a “One Time Consultation” to the
Provider in order to address the following Applicant issues:
1)Determine if Events relating to injury is “considered sudden and extraordinary.”
2)If “complaints of stress meet 51% threshold...”
Opportunity to Dispute Eligibility communicated with Claims Administrator on 02/01/2015; Response received
02/15/2016 indicating initial claim only recently received and is currently in process for review. However, submitted
documentation indicates the following processed dates for this claim:
Initial EOR Processed 11/25/2015 DCN # 5120151112078222
Final EOR Processed 01/12/2016, DCN # 8120161223082141
EOR’s indicate 95% Contract Rate
Psychological Report reviewed for 99354. Page 1, the Provider indicates Face-to-Face interview required “2 hours (4-6
PM).”EOR indicates 99205 60 min New Patient Evaluation and Management services. EOR indicates Provider reimbursed for
99204. Based on reported time and nature of evaluation, 99205 time component dictates the level of service.
96101-59 Psychological Testing Per Hour is a paired code to 99205. However, the reported Modifier and Documentation
support standalone services.
Page 1 of Psychological report, the Provider indicates “Administration, scoring and interpretation of psychological testing
required 4 hours.”
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 96105-59 and 99354
.

42. 96101-59, 96102,
90899, and WC007
The Claims Administrator denied
codes with rationale
“
Communication from Legal Parties authorizing Med-Legal services reviewed.
Code Description CPT 96101 Psychological; testing (includes psychodiagnostic
assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., mmpi, rorschach, wais), per hour of the
psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results
and preparing the report.
96102: Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by
technician, per hour of technician time, face-to-face.
Page 1 of the Provider’s Psychological Consultation Report documents “6 hours of Psychological test completion and
interpretation by a psychologist; 96102-59 for 1 additional hour of test assessment and scoring by a psychologist”
Per Correct Coding Policies for NCCI Policy Manual for Medicare Services, 1/1/2015 chapter 1 Mutually Exclusive Procedures-
Many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually exclusive
procedures cannot reasonably be performed at the same anatomic site or same patient encounter.
CPT codes 96101 and 96102 are mutually exclusive of each other and cannot be reimbursed separately. Therefore,
reimbursement of 96102 is not warranted.
A pair code does exist between reimbursed code 99205 and 96101, however, modifier indicator column shows ‘1’stating that if
an approved modifier is appended to the column ‘2’ code, and documentation supports billed code, then the edit may be
overridden.
Column ‘2’ code 96101 has approved modifier -59 appended and documentation does support billed code. Reimbursement of
96101 is warranted.
Request for Authorization shows “Service/Good Requested: Psych Consultation, Extended Time, Testing Interpretation by
Tech., Psychological Testing and Report; CPT/HCPCS code: 99205, 99354, 96102, 96101 and WC007” and is signed and dated
10/9/15 by Claims Administrator showing “Approved”
Based on aforementioned guidelines and documentation, additional reimbursement of 96101 and WC007 is warranted

43. 96118 and 90791 The Claims Administrator’s
reimbursement for services was
based on an indicated “contract.”
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking full OMFS remuneration for 96118 Neuropsych
Testing and 90791 Psych Diagnostic Evaluation services performed 01/08/2015.
The Claims Administrator’s reimbursement for services was based on an indicated “contract.”
Authorization 01/14/2015 with stamped signature by Claims Administrator agreed to the following for 96118 and 90791
services: “Agree to pay based on CA fee Schedule,” hand written on authorization.
EOR’s reflect charges based on “PPO” reduction.
Initial Neuropsychological Evaluation reviewed, time is documented for codes in dispute. Pursuant to LC § 5307.11: A health
care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant
to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety
Code, and a
contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee
schedule for that health care provider or healthfacility licensed pursuant to Section 1250 of the Health and Safety Code shall not
apply to the contracted reimbursement rates.
Based on the aforementioned documentation and guidelines, additional remuneration is
warranted for 96118 and 90791.

44. 96118-59 Claims Administrator denied code
indicating on the Explanation of
Review “CCI: Standards of
Medical/Surgical Practice” and
“included within the value of
another service performed on the
same day”
Provider is dissatisfied with denial of code 96118-59.
Claims Administrator denied code indicating on the Explanation of Review “CCI: Standards of Medical/Surgical Practice” and
“included within the value of another service performed on the same day”
RFA dated 12/09/2014 documents CPT codes 99205, 99354, 99358, 96118 and WC005.
As a pair code does exist between codes 96118 and 99205 , Provider appended modifier -25 to 96118. Modifier -25: Significant,
separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service.
Per NCCI Edits, status indicator column shows ‘1’ which states that if an approved modifier is appended to the column ‘2’ code,
and documentation is submitted to support the billed code, then the edit may be overridden.
Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:Anatomic modifiers:
E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI; Global surgery modifiers: 24, 25, 57, 58, 78, 79; Other modifiers:
27, 59, 91, XE, XS, XP, XU
Provider appended modifier -25 which is one of the approved modifiers.
CPT 96118 -Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and
Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the
patient and time interpreting these test results and preparing the report
Report dated June 12, 2015 titled Comprehensive Initial Neuropsychological Evaluation Report , documents
“evaluation consisted of 2 hours of face-to-face interview with the patient and 13 hours of testing, scoring and interpretation. ”
Pages 6 & 7 of Provider’s report documents tests administered.
Documentation submitted supports billed code 96118.
Based on information reviewed, reimbursement of 96118 is warranted.
EOR received reflects a 10% PPO discount is to be applied to reimbursement.
The table below describes the pertinent claim line inform

45. 97110-GP The Claims Administrator’s
reimbursement rational indicates:
“Contract Rate.”
9789.15.4 Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Authorization for
Specified Procedure/Modality Services (1) The Medicare Multiple Procedure Payment Reduction (“MPPR”) for “Always
Therapy” Codes shall be applied when more than one of the following codes is billed on the same day: codes on the Medicare
“Always Therapy” list, acupuncture codes, chiropractic manipulation codes. (2) Many therapy services are time-based codes, i.e.,
multiple units may be billed for a single procedure. The MPPR applies to the Practice Expense (“PE”) payment when more
than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as
multiple procedures. Full payment is made for the unit or procedure with the highest PE payment. Full payment is made for the
work and malpractice components and 50 percent payment is made for the PE for subsequent units and procedures, furnished to
the same patient on the same day
97113-59 Claims administrator denied code
indicating on the 1st Explanation of
Review “ please provide chart notes
or office notes so we can proceed
with the correct payment
Per NCCI Edits mentioned, generally codes 97150 and 97113 are not billed together. However, Modifier Indicator column shows
‘1’ which states if the correct code has an approved NCCI modifier appended, and documentation is submitted to support code
used, then the edit may be overridden.
Modifier -59 is an approved modifier and may be used to support billed code 97113. We billed CPT 97113 with modifier -59
on the CMS 1500 form for both dates of service.
97113 -Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises.
 Documentation received included Daily Note/Billing Sheet which documents services Performed 97113 as well as
service 97150Documented start and stop time for each procedure submitted
97140 Service denied by Claims
Administrator as “Mutually
exclusive procedures.”
Provider seeking remuneration for 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic
drainage, manual traction), 1 or more regions, each 15 minutes performed on dates of service 07/20/2015, 07/22/2015 &
07/29/2015 .
Service denied by Claims Administrator as “Mutually exclusive procedures.”
Provider billed code along with 98940 on a CMS 1500 form for all three dates of service.
As pair code does exist between 97140 and 98940, modifier indicator column shows ‘1’ which states that if an approved
modifier is appended to the column 2 code, and documentation supports billed code, then the edit may be overridden.
Provider appended approved modifier ‘XS’-Separate Structure, A service that is distinct because it was performed on a separate
organ/structure , to column 2 code 97140.
Progress notes document service 97140 as myofascial release to the forearm and CMT to T1.
Documentation supports services performed.
Opportunity to Dispute sent to Claims Administrator on 11/16/2015; response not yet received.
Based on the aforementioned documentation, reimbursement is indicated for 97140x 3.
EOR received reflects a 10% PPO discount to be applied to reimbursement

46. 97530 x 4 Units The Claims Administrator denied
the services indicating: “Per CCI
Edits, the value of this procedure is
included in the value of the
mutually exclusive procedure.”
Provider seeking remuneration for 97530-59 x 4 Units Physical Medicine services performed on 02/26/2014 –03/05/2014.
The Claims Administrator denied the services indicating: “Per CCI Edits, the value of this procedure is included in the value of
the mutually exclusive procedure.”
NCCI edits reveal 97530 is Colum 2 Code when billed with Colum 1 Code, 97140.
Under certain circumstances, the paired codes in question may be unbundled with the use of modifier
-59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same
patient encounter.”
Documentation of Patient visit includes Exercise Log noting duration of each exercise.
Documentation regarding start and end times for 97530 Therapeutic Exercise and 97140 Manual Exercise, were not noted.
Times entries for each exercise did not clarify whether the
sessions were performed separately, simultaneously, or sequentially Provider seeking remuneration for
97530-59 x 4 Units Physical Medicine services performed on 02/26/2014 –03/05/2014.
The Claims Administrator denied the services indicating: “Per CCI Edits, the value of this procedure is included in the value of
the mutually exclusive procedure.”
NCCI edits reveal 97530 is Colum 2 Code when billed with Colum 1 Code, 97140.
Under certain circumstances, the paired codes in question may be unbundled with the use of modifier
-59 provided the “two procedures of a code pair edit are performed in different timed intervals even if sequential during the same
patient encounter.”
Documentation of Patient visit includes Exercise Log noting duration of each exercise.
Documentation regarding start and end times for 97530 Therapeutic Exercise and 97140 Manual Exercise, were not noted.
Times entries for each exercise did not clarify whether the sessions were performed separately, simultaneously, or sequentially

47. 97530-59 Claims Administrator denied codes
and indicated on the Explanation of
Review “Per CCI edits, the value of
this procedure is included in the
value of the mutually exclusive
procedure.”
Provider is dissatisfied with denial of CPT 97530-59. Provider billed codes 97140, G0283 and 97530
-59.
97530 is a time based code each 15 minutes.
Claims Administrator denied codes and indicated on the Explanation of Review “Per CCI edits, the value of this procedure is
included in the value of the mutually exclusive procedure.”
NCCI edits state that generally 97140 and 97530 are not reported together. However, Modifier Indicator column shows ‘1’
which states if the appropriate modifier is appended to the correct code, and proper documentation is supporting the code, then
the NCCI edit may be overridden.
Pursuant to Labor Code section 5307.27, MTUS shall address, at a minimum, “the frequency, duration, intensity, and
appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.”
On review of documentation submitted which included the testing that was done on date of service
05/02/2014 . Provider documents time for CPT 97530 and 97140 with description of procedures performed. Therefore,
reimbursement of 97530-59 is recommended.
Claims Administrator shows a PPO discount of 15% was applied to reimbursement which was not disputed. Therefore, 15%
discount shall be applied.

48. 97530-59 and 97750-
59
97530 and 97750 are both time
based codes each 15 minutes.
Claims Administrator denied codes
and indicated on the Explanation of
Review “Per CCI edits, the value of
this procedure is included in the
value of the comprehensive
procedure.”
Provider is dissatisfied with denial of CPT 97530-59 and 97750-59. Provider billed codes 97140, G0283, 97530-59 and 97750 -
59.
97530 and 97750 are both time based codes each 15 minutes.
Claims Administrator denied codes and indicated on the Explanation of Review “Per CCI edits, the value of this procedure is
included in the value of the comprehensive procedure.”
NCCI edits state that generally 97140, 97530 and 97750 are not reported together. However, Modifier Indicator column shows
‘1’ which states if the appropriate modifier is appended to the correct code, and proper documentation is supporting the code,
then the NCCI edit may be overridden.
Pursuant to Labor Code section 5307.27, MTUS shall address, at a minimum, “the frequency, duration, intensity, and
appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.”
On review of documentation submitted which included the testing that was done on date of service 5/07
/2014, no start and stop times are recorded as needed for code 97750. Provider documents time for CPT 97530 but not 97750.
Therefore, reimbursement of 97750 is not recommended.
Claims Administrator shows a PPO discount of 15% was applied to reimbursement which was not disputed. Therefore, 15%
discount shall be applied.

50. 97545 The Claims Administrator denied
reimbursement as “not reimbursable
under Medicare Hospital Outpatient
Fee Schedule.”
Provider seeking $195.00 in remuneration for 97545 Work Conditioning services performed on 04/15/2015.
The Claims Administrator denied reimbursement as “not reimbursable under Medicare Hospital Outpatient Fee Schedule.”
OMFS 97545 Code Definition: Work Conditioning (97545) is a work related, intensive, goal oriented treatment program
specifically designed to restore an individual's systemic, neuromusculoskeletal (strength, endurance, movement, flexibility, and
motor control) and cardiopulmonary functions. The objective of the Work Conditioning program is to restore the client's
physical capacity and function so the injured worker can return to work. Prior authorization is required.
CPT 97545 is a reimbursable service under the OMFS pursuant to CCR § 9789.32, “Other Services,” and is a “By Report ”
procedure code.
Authorization dated 02/24/2015, signed by RN Case Manager reflects “6 sessions,” as “approved.”
97545 reflected on the OMFS has a Relative Value of “0” and there is no comparable service code.
OMFS: General Information and Instructions, Physical Medicine: In some instances the values of BR procedures may be
determined using the value assigned to a comparable procedure. The comparable procedure should reflect the same amount of
time, complexity. expertise etc., as required for the procedure performed.
A “comparable” service does not exist for this comprehensive program and is treated as a ‘By Report’ code where a Contractual

51. Agreement or the Provider’s Usual and Customary charge dictates reimbursement.
Opportunity to Dispute Edibility sent to Claims Administrator on 09/30/2015; response not yet received.
PPO Contractual Agreement not available for IBR.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97545.
97545 The Claims Administrator denied
reimbursement as “not reimbursable
under Medicare Hospital Outpatient
Fee Schedule.”
Provider seeking $195.00 per unit remuneration for 97545 Work Conditioning services performed on 03/16/2015, 03/27/0015,
04/01/2015 & 04/08/2015.
The Claims Administrator denied reimbursement as “not reimbursable under Medicare Hospital Outpatient Fee Schedule.”
OMFS 97545 Code Definition: Work Conditioning (97545) is a work related, intensive, goal oriented treatment program
specifically designed to restore an individual's systemic, neuromusculoskeletal (strength, endurance,
movement, flexibility , and motor control) and cardiopulmonary functions. The objective of the Work Conditioning program is to
restore the client's physical capacity and function so the injured worker can return to work. Prior
authorization is required.
CPT 97545 is a reimbursable service under the OMFS pursuant to CCR § 9789.32, “Other Services,” and is a “By Report”
procedure code.
Authorization dated 02/24/2015, signed by RN Case Manager reflects “6 sessions,” as “approved.”
97545 reflected on the OMFS has a Relative Value of “0” and there is no comparable service code.
OMFS: General Information and Instructions, Physical Medicine: In some instances the values of BR procedures may be
determined using the value assigned to a comparable procedure. The comparable procedure should reflect the same amount of
time, complexity. expertise etc., as required for the procedure performed.
A “comparable” service does not exist for this comprehensive program and is treated as a ‘By Report ‘code where aContractual
Agreement or the Provider’s Usual and Customary charge dictates reimbursement.
Opportunity to Dispute Edibility sent to Claims Administrator on 09/30/2015; response not yet received.
PPO Contractual Agreement not available for IBR.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97545

52. 97670-30-86 EOR’s reflect the following:
1st EOR: 1) Pre-Authorization
Required 2)Authorization Number
Invalid or Missing.
 2nd EOR: 1) Reimbursement of
$403.75 2) per Pre-Authorization
and Labor Code.
01/04/2016Final EOR: 1) Pre-
Authorization Required 2)
Documentation Does not support a
significant identifiable E&M
Service 3) Per LC 5307.1
Provider seeking additional remuneration for 97670-32 Functional capacity measurement (e.g., combination of standardized tests
of strength, flexibility, weight lifting, weight carrying , and pushing and
pulling movements to determine functional ability); including report; requires prior authorization
for date of service 07/10/2013.
EOR’s reflect the following:
1st EOR: 1) Pre-Authorization Required 2)Authorization Number Invalid or Missing.
 2nd EOR: 1) Reimbursement of $403.75 2) per Pre-Authorization and Labor Code.
01/04/2016Final EOR: 1) Pre-Authorization Required 2) Documentation Does not support a
significant identifiable E&M Service 3) Per LC 5307.1
CMS 1500 reflects the following:
Original and Subsequent HCFA -Authorization Number not reflected in box 23.
CPT 97670-30-86-WP–Original CMS 1500
CPT 97670-WP–SBR submission
Modifiers listed on CMS 1500 that are not relevant to case; supportive documents not submitted for IBR:
30-Consultation Service During Medical Legal Evaluation
32 –Mandated Consultation
WP –Whole Procedure or Impairment Rating –Not relevant to California Specific Billing Codes.
Relevant Modifier : 86 –
“This Modifier is used when prior authorization was received for services that exceed OMFS ground rules.”
Authorization dated 07/27/2013, Authorization Number: FICMTCAD0000036790, reflects the
following: "Referral to (Provider) for FCE for the cervical spine." Authorized through 06/27/2013 To 09/25/2013.
Requirement Met for Modifier -86.
OMFS Physical Medicine General Instructions 97670 Code Description: Functional capacity measurement (e.g., combination of
standardized tests of strength, flexibility, weight lifting, weight carrying , and pushing and pulling movements to determine
functional ability); including report; requires prior authorization.
Prior Authorization Requirement Met for OMFS 97670 code Description.
97670 is a By Report Code; there is no unit value.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”§9789.12.4 (c)
“In determining the value of a By Report procedure, consideration may be given to the value assigned to a comparable procedure
or analogous code. The comparable
procedure or analogous code should reflect similar amount of resources, such as practice

53. expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97670 or, more specifically,
A Functional Capacity examination and a comparable procedure code does not exist.
In absence of a Contractual Agreement, the OMFS allows reimbursement based on the Provider’s Usual and Customary charge.
Opportunity to Dispute communicated to Claims Administrator on 01/19/2016; response not yet received.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for 97670 x 1 unit.
97750 EOR’s indicate charges “exceeded
the scheduled allowance.”
Provider seeking additional remuneration for 97750 Physical Performance test performed on 07/17/2015.
EOR’s indicate charges “exceeded the scheduled allowance.”
CPT 97750 Code Description: Physical performance test or measurement (eg, musculoskeletal, functional capacity), with
written report, each 15 minutes. (Emphasis added).
AMA CPT 97750 code description indicates, “requires direct face-to-face contact,” meaning , a
written report is included in the value of the code and are not separately reportable outside of direct face
-to face contact. (Emphasis added)
The calculation of the Maximum Reasonable Fee for 97750 is based on time spent performing direct face-to-face contact.
Submitted dictation for procedure 97750 indicates total hours spent but does not indicate how many hours spent on direct face-to-
face contact with the Injured Worker. Per AMA CPT,
Introduction section, “Time is the face-to-face time with the patient.” (Emphasis added)
EOR’ s reflect services reimbursed at total of $492.95; higher than the OMFS reasonable cost calculations of $461.72.
Billed Amount * State Cost to Charge Ratio * Dept. of Labor OWCP Adjustment Factor
Without documentation regarding time spent with direct face-to-face contact with the Injured Worker, the OMFS allowable is x
1 unit @ $43.96.
Based on the aforementioned documentation and guidelines, additional reimbursement is not indicate

54. 97750 Claims administrator reimbursed
$956.41 indicating on the
Explanation of Review “Pricing
reductions due to MPN
Provider is dissatisfied with reimbursement of code 97750
Claims administrator reimbursed $956.41 indicating on the Explanation of Review “Pricing reductions due to MPN ”
Provider states “The adjuster agreed to the rate on our RFA per email dated 9-19-14. Rate is $3,000.00 for 8 hrs/$93.75 per unit”
Claims administrator submitted a documented dispute stating “There is a contractual issue –the discount taken was die to PPO
contract.”
Provider’s Request for Authorization included “Service/Good Requested: Functional Capacity Evaluation with provider;
CPT/HCPCS Code: 97670; Frequency, Duration Quantity, etc: 8 hours = $3,000”.
Claims administrator’s email dated July 10, 2014 states “I approved for whatever was ordered by the doctor on the RFA.”
Provider billed CPT code 97750 on a CMS 1500 form. Provider also documents on the IBR application under Please select all
applicable Fee Schedules: Contract Reimbursement Rates.
Claims administrator states “If the dispute centers on the applicability of the contract in place, it must be rejected, as rule
§9792.5.7(b) requires this to be resolved first before proceeding to IBR”
The dispute appears to be a contract issue which is not to be determined by the reviewer.
Based on information reviewed, additional reimbursement for code 97750 is not warranted

55. 97750 x 12 EOR does not indicate 97750 as
unauthorized but does state “No
separate payment was made because
the value of The service is included
within the value of another service
performed on the same day”
Provider is dissatisfied with denial of CPT 97750, Physical performance test or measurement (eg, musculoskeletal, functional
capacity), with written report, each 15 minutes
EOR does not indicate 97750 as unauthorized but does state “No separate payment was made because the value of The service
is included within the value of another service performed on the same day”
EORs received only show CPT code 97750 billed along with CMS 1500 form billing only 97750.
Provider’s report submitted documents 2 hours spent face to face and 60 minutes of report preparation
Opportunity to Dispute sent to Claims Administrator 08/12/2015; response not yet received
Based on the aforementioned documentation and guidelines, additional reimbursement is
warranted for 97750 x12
Provider states a 10% PPO discount is to be applied to reimbursement
97750 x 32 ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE IN DISPUTE
:
Provider is seeking remuneration of CPT 97750

56. for d
ate of
service
02/12/2016
.

Claims Administrator’s denial rationale
:
1.
“
Identify time spent to perform services
”
2.
“Claim/service lacks information or has submission/billing error(s) which is
needed for adjudication”
3.
“Documentation of the time spent performing
this service is needed for further
review”

CPT 97750
-
Physical performance test or measurement (eg, musculoskeletal, functional
capacity), with written report,
each 15 minutes
.

97750 is a time
-
based code requiring time spent face
-
to
-
face with the patien
t.

Provider’s Functional Capacity Evaluation Report does not d
ocument a start and stop
time
with the patient.

Authorization or a request
for functional Capacity Evaluation not identified in review.


57. Administrative Rules § 9792.6. Utilization Review Standard
s
–
Definition (a)
“Authorization” means
assurance
that appropriate reimbursement will be made for
an approved specific course of proposed medical treatment
to cure or relieve the
effects of the industrial injury pursuant to section 4600 of the Labor Code, subject to the
provisions of section 5402 of the Labor Code, based on either a completed “Request for
IBR Final Determination UPHOLD, Practitioner
CB16-0000706
Page 3 of 3
Authorization,” DWC Form RFA, as contained in Califor
nia Code of Regulations, title 8,
section 9785.5, or a request for authorization of medical treatment accepted as complete
by the claims administrator under section 9792.9.1(c)(2), that has been transmitted by the
treating physician to the claims administrator. Authorization shall be given pursuant to
the timeframe, procedure, and notice requirements of California Code of Regulations,
title 8, section 9792.9.1, and may be provided by utilizing the indicated response section
of the “Request for Authorization,” DWC Form RFA if that form was initially submitted
by the treating physician.

§ 9792.5.7 (b) unless
as permitted by section 9792.5.12, independent bill review shall
only be conducted if the only dispute between the provider and the claims administrator
is the amount of payment owed to the provider. Any other issue, including issues of
contested liability or the applicability of a contract for reimbursement rates under Labor
Code 5307.11 shall be resolved before seeking independent bill review.

Reimbursement of 97750 x 32 units is not warra
97750 x 32 Provider is seeking remuneration of CPT 97750 for date of service 02/12/2016.

58. Claims Administrator’s denial rationale:
1.“Identify time spent to perform services”
2.“Claim/service lacks information or has submission/billing error(s) which is needed for adjudication”
3.“Documentation of the time spent performing this service is needed for further review”
CPT 97750 -Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15
minutes.
97750 is a time-based code requiring time spent face-to-face with the patient.
Provider’s Functional Capacity Evaluation Report does not document a start and stop time with the patient.
Authorization or a request for functional Capacity Evaluation not identified in review.
Administrative Rules § 9792.6. Utilization Review Standards –Definition (a) “Authorization” means
Assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment to cure or
relieve the effects of the industrial injury pursuant to section 4600 of the Labor Code, subject to the provisions of section 5402 of
the Labor Code, based on either a completed “Request for Authorization,” DWC Form RFA, as contained in California Code of
Regulations, title 8,
section 9785.5, or a request for authorization of medical treatment accepted as complete by the claims administrator under section
9792.9.1(c)(2), that has been transmitted by the treating physician to the claims administrator. Authorization shall be given
pursuant to the timeframe, procedure, and notice requirements of California Code of Regulations, title 8, section 9792.9.1, and
may be provided by utilizing the indicated response section of the “Request for Authorization,” DWC Form RFA if that form was
initially submitted by the treating physician.
§ 9792.5.7 (b) unless as permitted by section 9792.5.12, independent bill review shall only be conducted if the only dispute
between the provider and the claims administrator
is the amount of payment owed to the provider. Any other issue, including issues of
contested liability or the applicability of a contract for reimbursement rates under Labor
Code 5307.11 shall be resolved before seeking independent bill review.

Reimbursement of 97750 x 32 units is not warranted.
97799
-
86
ISSUE IN DISPUTE
:
Provider seeking remuneration for
Functional Restoration
Program services, billed as Unlisted Procedure Code 97799
-
86 for date

59. s
of service
12/07/2015
–
12/09/2015
.

The Claims Administrato
r denied reimbursement as “
provider was not
part
of the Medical
Provider Network
.”

Modifier
-
86: OMFS
Modifier is used when prior authorization was received for services
that
exceed OMFS ground rules.

Request for
Aut
horization for Functional Restoration Program
(Multidisciplinary)
service
using code 97799
w
ith a daily rate of $1200.00 ($6
000 per week)
submitted for review.

Authorization
fo
r Functional Restoration Program
presented for IBR, dated
10
/
15/
2015,
reflecting “
F
unctional Restoration Program 10 days/50 hours

60. ”
by
the
Utilization Review
,
indicates t
reatment
as
“
certified
,
” meeting t
he criteria for Modifier
-
86
.

Report
submitted documents services perfo
rmed on dates of service
12/07/2015
–
12/09/2015
.

OMFS allows for Unlisted Procedure Codes
to be reimbursed by “By Report
”

CCR
§
9789.12.4 (c)
“In determining the value of a By Report procedure, consideration may
be given to the value assigned to a
comparable
procedure or analogous code. The
compar
able procedure or analogous code should reflect similar amount of resources, such as
practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
IBR Final Determination OVERTURN, Practitioner CB16-0000885
Page 3 of 3

There is no allowance or comparable code listed under the OMFS for service billed with
procedure code 97799 or, more specifically, a Functional Restoration Program; a CPT Code

61. has yet to be formulated for this comprehensive program. As such, a contractual agreement
or the OMFS will dictate the level of reimbursement.

Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable
at the Provider’s Usual and Customary Charge.

Contractual Agreement not submitted for IBR.

Based on the aforementioned documentation and guidelines, reimbursement is
indicated for 97799-86
97799
-
86
Provider dissatisfied with reimbursement of code 97799-86
Provider was reimbursed $998.23 and is seeking additional reimbursement of $4131.77.
Explanation of Review reflects a partial payment to the Provider in the amount of $998.23 and indicated “No more than 4
physical medicine modalities and/or procedures may be reimbursed in one visit. Reimbursement for physical medicine
procedures, modalities, including chiropractic manipulation and acupuncture codes are limited to 60 minutes per visit without
prior authorization pursuant to physical medicine rule 1 (c).”
Provider’s appeal states their program “emphasizes the importance of function over the elimination of pain” through physical
treatment, medical care and supervision, psychological and behavioral care, psychosocial care, vocational care, rehabilitation and
training and education in nutrition, medication management and ergonomics and stress management. They are staffed by licensed
Physical Therapists, Psychologists, as well as Board-Certified Pain Management Specialists.
Based on review of the FRP Weekly Progress Report stating the injured worker’s treatment for the week, along with the
Physical Therapy Progress Report, Physician’s Progress Report, Psychological and Behavioral Progress Note which detail the
comprehensive and intense pain program this injured worker is completing, procedure code 97799-86 is substantiated as the
Provider documented services performed.
The Physician’s Report details the injured worker’s medical history, current medications, physical examination with
accomplishments including functional strength, range of motion, functional movement and lifting, psychological evaluation,
treatment plan and a formal request for authorization, demonstrating that a thorough evaluation was performed on this injured
worker.
Other documents reviewed include the Request for Authorization of Medical Treatment for CPT code 97799 x 160 Hours at
$225 an hour.

62. Utilization Review Approved 80hours of Functional Restoration Program dated October 21, 2013.
PPO Contract was reviewed which shows a 5% discount is to be applied.
97799 Provider is dissatisfied with reimbursement of 97799 for Functional Restoration Program.
Claims Administrator reimbursed $855.00 indicating on the Explanation of Review “No more than 4 physical medicine
modalities and/or procedures may be reimbursed in one visit”
Included for review is the Request for Authorization of Medical Treatment for 97799 x 80 hours at $225 per hour dated
04/18/2014.
Utilization Review states “Treatment Plan Requested: Functional Restoration Program (80 hours)
Determination: Certified Details (if applicable) Decision Date: 04/25/2014 Authorization Timeframe: 04/21/2014 –06/21/2014”
”
Based on review of the Physician’s Weekly Progress Report, Physical Therapy Report, Psychological & Behavioral Progress
Note, procedure code 97799 is substantiated as the Provider documented services performed.
The Physician Evaluation details the injured worker’s medical history, current medications; physical examination including
functional strength, range of motion, function movement and lifting, dynamic
posture and stabilization, psychological evaluation, treatment plan and a formal request for authorization, a thorough evaluation
was performed on this injured worker.
PPO Contract received shows a 5% discount is to be applied. The table below describes the pertinent claim line information.
DETERMINATION OF ISSUE IN DISPUTE: Reimbursement of code 97799-86 is warranted.

63. 97799 Claims Administrator reimbursed
$5131.95 indicating on the
Explanation of Review “Approved
by Utilization Review”
Provider is dissatisfied with reimbursement of 97799 for Functional Restoration Program.
Claims Administrator reimbursed $5131.95 indicating on the Explanation of Review “Approved by Utilization Review”
Included for review is the Request for Authorization of Medical Treatment for 97799 x 160 hours at $225 per hour dated
03/20/2014.
Approved authorization from Utilization Review states “Recommend CERTIFICATION of outpatient Northern California
Functional restoration program 80 hrs. (10 days) (03/27/2014-05/09/2014)””
Based on review of the Physician’s Weekly Progress Report, Physical Therapy Report, Psychological & Behavioral Progress
Note, procedure code 97799 is substantiated as the Provider documented services performed.
The Physician Evaluation details the injured worker’s medical history, current medications; physical examination including
functional strength, range of motion, function movement and lifting, dynamic posture and stabilization, psychological evaluation,
treatment plan and a formal request for authorization, a thorough evaluation was performed on this injured worker.
PPO Contract received shows a 5% discount is to be applied
97799
Sample: Progress
Notes for FRP
Claims Administrator reimbursed
$5131.95 indicating on the
Explanation of Review “Approved
by
Utilization Review”
Based on review of the Physician’s Weekly Progress Report, Physical Therapy Report, Psychological & Behavioral Progress
Note, procedure code 97799 is substantiated as the Provider documented services performed.
The Physician Evaluation details the injured worker’s medical history, current medications; physical examination including
functional strength, range of motion, function movement and lifting, dynamic posture and stabilization, psychological evaluation,
treatment plan and a formal request for authorization, a thorough evaluation was performed on this injured worker
Provider is dissatisfied with reimbursement of 97799 for Functional Restoration Program.
Claims Administrator reimbursed $5131.95 indicating on the Explanation of Review “Approved by

64. Utilization Review”
Included for review is the Request for Authorization of Medical Treatment for 97799 x 160 hours at $225 per hour dated
03/20/2014.
Approved authorization from Utilization Review states “Recommend CERTIFICATION of outpatient Northern California
Functional restoration program 80 hrs. (10 days) (03/27/2014-05/09/2014)””
Based on review of the Physician’s Weekly Progress Report, Physical Therapy Report, Psychological & Behavioral Progress
Note, procedure code 97799 is substantiated as the Provider documented services performed.
The Physician Evaluation details the injured worker’s medical history, current medications; physical examination including
functional strength, range of motion, function movement and lifting, dynamic posture and stabilization, psychological evaluation,
treatment plan and a formal request for authorization, a thorough evaluation was performed on this injured worker.
PPO Contract received shows a 5% discount is to be applied
97799 86 Provider dissatisfied with reimbursement of code 97799-86
Based on review of the Physician’s Initial Evaluation, procedure code 97799-86 is substantiated as the Provider documented
services performed and Provider’s Usual and Customary charge.
The Physician Evaluation details the injured worker’s medical history, current medications,physical examination including
functional strength, range of motion, function movement and lifting, dynamic posture and stabilization, psychological evaluation,
treatment plan and a formal request for authorization, a thorough evaluation was performed on this injured worker
Documents reviewed included a Request for Medical Treatment for 160 hours of NCFRP at $225.00 per hour.
Utilization Review Notice indicated services certified as 160 hours of Functional Restoration
Program over 6 weeks, certification period: 10/21/2013 –10/20/2014 80 hours of 3 weeks.
Weekly progress report week documented: 29 hours ; Medical and Psychological
Evaluation; musculoskeletal evaluation; range of motion; strength; functional improvement; physical therapy progress report;
behavioral and psychological progress report.
PPO Contract was reviewed which shows “Medical treatment shall be reimbursed at ninety-four percent (95%) of eligible billed
charges for covered services billed with a procedure code for which there is no assigned value.

65. 97799 86
Initial
Interdisciplinary
Evaluation
Reduction not stated Provider dissatisfied with reimbursement of code 97799-86
Based on review of the Physician’s Initial Evaluation, procedure code 97799-86 is substantiated as the Provider documented
services performed and Provider’s Usual and Customary charge.
The Physician Evaluation details the injured worker’s medical history, current medications, physical examination including
functional strength, range of motion, function movement and lifting, dynamic posture and stabilization, psychological evaluation,
treatment plan and a formal request for authorization, a thorough evaluation was performed on this injured worker
Documents reviewed included the Request for Authorization of Medical Treatment for an Initial Interdisciplinary Evaluation
documenting Provider’s cost at $2500.00.
Claims Administrator’s Approval letter of Initial Evaluation reviewed
PPO Contract applied 5% discount
Claims Administrator’s Approval letter of Initial Evaluation reviewed
PPO Contract applied 5% discount
97799 -86
60% PPO
Claims Administrator denied FRP
services stating, “The Official
Medical Fee Schedule does not list
code. Multiple Procedure Payment
Rule Applied”
Provider seeking full remuneration for Functional Restoration Initial Evaluation services, billed as Unlisted Procedure Code
97799-86, for date of service 04/10/2014.
Claims Administrator denied FRP services stating, “The Official Medical Fee Schedule does not list code. Multiple Procedure
Payment Rule Applied”
Functional Restoration Program service not in dispute.

66. Payment for FRP is in dispute.
Providers Usual and Customary fee of $2,500.00 as stated on 4/10/2014 FRP Report.
Authorization for FRP signed by Claims Administrator on 10/25/2013 with expiration date for service 5/31/2014.
Authorization did not indicate capitation for FRP service.
Submitted documentation included a page of the PPO contract indicating “95% of the reasonable maximum fees established by
California Workers’ Compensation...”
There is no allowance listed under the OMFS for the billed procedure code 97799 Modifier 86.
Provider documented usual and customary charge of $2,500.00 in the treatment report submitted to the Claims Administrator.
Partial contract indicates “Unlisted Services” at a reimbursement of 60%
of Provider’s usual and customary billed charges.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted @ 60% for 97799-86
97799-86 Provider dissatisfied with reimbursement of code 97799-86
Provider was reimbursed $213.75 and is seeking additional reimbursement of $5557.50 .
Claims Administrator sent a partial paymentindicating on the Explanation of Review: “
The charge exceeds the Official Medical Fee Schedule allowance. The charge has been adjusted to the scheduled
allowance.”Claims Administrator fails to document which Fee Schedule they have based
reimbursement on as 97799 is an unlisted code.
“Functional Restoration Programs are a type of treatment included in the category of interdisciplinary
pain programs. Functional Restoration Programs are designed to use medically directed, interdisciplinary pain management
approaches geared specifically for patients with chronic disabling occupational musculoskeletal disorders.”
Based on review of the FRP Weekly Progress Report stating the injured worker’s treatment for the
week, along with the Physical Therapy Progress Report, Physician’s Progress Report, Psychological
and Behavioral Progress Note which detail the comprehensive and intense pain program this injured
worker is completing, procedure code 97799-86 is substantiated as the Provider documented services
performed.
Also included was the Request for Authorization of Medical Treatment for 80 additional hours of

67. Functional Restoration Program documenting Provider’s cost at $225.00 an hour.
Claims Administrator’s Approval letter of additional 80 hours dated 04/28/2014is also noted.
PPO Contract was reviewed which shows a 5% discount is to be applied.
97799-86 Provider seeking additional remuneration for Functional Restoration Evaluation services, billed as Unlisted Procedure Code
97799-86, for date of service 01/06/2016 –01/08/2016 (3days).
The Claims Administrator’s reimbursement rational indicates the following: “Recommended
Allowance based on functional capacity evaluation,” and “contract indicated.”
Contractual Agreement provided for IBR reflects“ 95%” of eligible billed charges for procedure codes of no assigned value.
97999 is a By Report code; a schedule allowance does not exist and there is no assigned value.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically,
Functional Restoration Program, and a comparable procedure code does not exist.
CPT 97799 By Report Code is not subject to MPPR as there is no unit value or conversion factor associated with this By Report
Code.
Functional Restoration Program service authorized as per aforementioned 06/06/2016 addendum,
meeting the criteria for Modifier -86.
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that
exceed OMFS ground rules.”
The Provider’s Usual and Customary Fee is presented on RFA dated 11/30/2015 as “$225.00/hour.”
Authorization dated 11/30/2015 indicates the following “40 units “Physical Medicine Proced for Psychogenic pain Nec.”

68. Initial date: 11/24/2015
End date: 12/24/2015 extended to 02/28/2016
Opportunity to dispute Eligibility communicated with the Claims Administrator on 05/17/2016; response received 06/07/2016
with recent EORs indicating “additional payment.” However, the dates of services on the recent EOR do not reflect all of the
dates of service for this dispute; this review will not reflect this additional payment as reconciliation between recent reimbursed
amount and the dates of services for this dispute cannot be adequately reconciled.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this
section.
Based on the aforementioned documentation and guidelines, additional reimbursement
is indicated for Unlisted Procedure Code 97799-86
97799-86 Claims Administrator reimbursed
$2538.00 indicating on the
Explanation of Review
“Reimbursement for physical
medicine procedures, modalities,
including Chiropractic
Manipulation and acupuncture
codes are limited to 60 minutes per
visit without prior authorization
pursuant to Physical Medicine rule
1?”
empathy
Provider is dissatisfied with reimbursement of 97799 for Functional Restoration Program.
Claims Administrator reimbursed $2538.00 indicating on the Explanation of Review “Reimbursement for physical medicine
procedures, modalities, including Chiropractic Manipulation and acupuncture codes are limited to 60 minutes per visit without
prior authorization pursuant to Physical Medicine rule 1?”
Included for review is the Request for Authorization of Medical Treatment for 97799 x 160 hours at $225 per hour dated
03/10/2014.
Approved authorization from Utilization Review states “Extension of authorization through 07/18/2014 per 06/18/2014 RFA –
160 hours of NCFRP per report of 02/27/2014, RFA 03/10/2014”
Based on review of the Physician’s Weekly Progress Report, Physical Therapy Report, Psychological & Behavioral Progress
Note, procedure code 97799-86 is substantiated as the Provider documented services performed.
The Physician Evaluation details the injured worker’s medical history, current medications; physical examination including
functional strength, range of motion, function movement and lifting, dynamic posture and stabilization, psychological evaluation,

69. treatment plan and a formal request for authorization, a thorough evaluation was performed on this injured worker.
PPO Contract received shows a 6% discount is to be applied
97799-86 Provider seeking $1,322.00 in additional remuneration for Functional Restoration Evaluation services, billed as Unlisted
Procedure Code 97799-86, for date of service 01/25/2016(1day).
The Claims Administrator’s reimbursement rational indicates the following: “This charge was adjusted to comply with the rate
and rules of the contract indicated.”
Carrier Code 808 indicates “Prior Authorization was received for services that exceed the OMFS
Ground Rules.”
Contractual Agreement provided for IBR reflects “95%” of eligible billed charges for procedure codes of no assigned value.
97999 is a By Report code; a schedule allowance does not exist and there is no assigned value.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial Functional
Restoration Program, and a comparable procedure code does not exist.
CPT 97799 By Report Code is not subject to MPPR as there is no unit value or conversion factor associated with this By Report
Code.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
EOR, Bill Control Number 1011372407 SW, Check 891A 87080228, reflect Carrier Code 808
indicating“ Prior Authorization was received for services that exceed the OMFS Ground Rules.”
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
The Provider’s Usual and Customary Fee is presented on RFA dated 01/20/2016 as “$225.00/hour.”
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.

70. Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety
Code other than those specified in contracts subject to this section.
Opportunity to dispute Eligibility communicated with the Claims Administrator on 05/18/2016; response not yet received.
Based on the aforementioned documentation and guidelines, additional reimbursement
is indicated for Unlisted Procedure Code 97799-86
97799-86
Functional
Restoration
Evaluation
The Claims Administrator’s
reimbursement rational indicates the
following: “This charge was
adjusted to comply with the rate and
rules of the contract indicated.”
Provider seeking $1,813.85 in additional remuneration for Functional Restoration Evaluation
services, billed as Unlisted Procedure Code 97799-86, for date of service 01/11/2016 –01/12/2016
(2 days)
The Claims Administrator’s reimbursement rational indicates the following: “This charge was adjusted to comply with the rate
and rules of the contract indicated.”
Carrier Code 808 indicates “Prior Authorization was received for services that exceed the OMFS Ground Rules.”
Contractual Agreement provided for IBR reflects “95%” of eligible billed charges for procedure codes
of no assigned value.
97999 is a By Report code; a schedule allowance does not exist and there is no assigned value.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial Functional
Restoration Program, and a comparable procedure code does not exist.
CPT 97799 By Report Code is not subject to MPPR as there is no unit value or conversion factor associated with this By Report
Code.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
EOR , Bill Control Number 1011121973SW, Check 896D 87287579, reflect Carrier Code 808 indicating“ Prior Authorization
was received for services that exceed the OMFS Ground Rules.”
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
The Provider’s Usual and Customary Fee is presented on RFA dated 11/03/2015 as “$225.00/hour.”
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11

71. : 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this
section.
Opportunity to dispute Eligibility communicated with the Claims Administrator on
05/18/2016; response not yet received.
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Unlisted Procedure Code
97799-86.
97799-86
Initial Evaluation -
Functional
Restoration
Evaluation
Provider seeking additional remuneration for Initial Evaluation -Functional Restoration Evaluation
services, billed as Unlisted Procedure Code 97799-86, for date of service 01/20/2016 –01/22/2016.
The Claims Administrator’s reimbursement rational indicates the following: “This charge was adjusted to comply with the rate
and rules of the contract indicated.”
Contractual Agreement provided for IBR, reflects”95%” of Billed Charges.
97999 is a By Report code; a schedule allowance does not exist.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial Functional
Restoration Program , and a comparable procedure code does not exist.
CPT 97799 By Report Code is not subject to MPPR as there is no unit value or conversion factor associated with this By Report
Code.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a

72. contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Codeshall not apply to the contracted reimbursement rates.
Except as provided in subdivision (b) of Section 530 7.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this
section.
The Provider’s Usual and Customary Fee is presented on RFA dated 01/20/2016 as “$225.00/hour.”
Authorization for FRP dated 02/5/2016 signed by Claims Administrator reflects “Request: Additional 120 hours of NCFRP
(Functional Restoration Program), 6 hours daily –Monday through Thurs; 3 hours on Fridays (27 hours per week). Modified
Approval: additional 106 hours of NCFRP.” Reimbursement amount not reflected.
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
The aforementioned Authorization is contractual in nature.
Provider submitted claim for dates of service Wednesday 1/206 hours, Thursday 1/216 hours and
Friday 1/22/16 3 hours = total 15 hours x $225.00= $3,375.00 x 95% = $3,206.25.
Opportunity to dispute Eligibility communicated with the Claims Administrator on 5/5/2016; response not yet received.
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Unlisted Procedure Code
97799-86.
97799-86
Initial Functional
Restoration
Evaluation
EOR indicate The Claims
Administrator’s reimbursement was
based on Physical Medicine
rational.
Provider seeking full remuneration for Initial Functional Restoration Evaluation service , billed as Unlisted Procedure Code
97799-86, for date of service 10/01/2015.
EOR indicate The Claims Administrator’s reimbursement was based on Physical Medicine rational.
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial Functional
Restoration Program Evaluation, and a comparable procedure code does not exist for this comprehensive multi-disciplinary

73. service.
The Provider’s Usual and Customary Fee is presented on the Authorization Request dated 08/26/2015as “$2,350.00.”
Authorization for Initial FRP dated 09/02/2015, Reference # 1781165, signed by Claims Administrator does not indicate a
procedure coded and does not indicate agreement of charges but does agree to Initial FRP evaluation and refer s to original RFA
of 08/26/2015. As such, the OMFS or contractual agreement dictates reimbursement for 97799-86.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
Recommend reimbursement for 1 unit of 97799-86 representing date of service 10/01/2015.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code,and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this
section.
The aforementioned Authorization is contractual in nature.
Opportunity to Dispute Eligibility communicated with the Claims Administrator on 05/02/2016; response not yet received.
Contractual Agreement not specified and not submitted for review.
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Unlisted Procedure Code
97799-86
97799-86
Initial Functional
Restoration Program
The Claims Administrator’s
reimbursement rational indicates the
following: “This charge was
adjusted to comply with the rate and
rules of the contract indicated.”
Provider seeking additional remuneration for Functional Restoration Evaluation services, billed as Unlisted Procedure Code
97799-86, for date of service 01/18/2016 –01/19/2016.
The Claims Administrator’s reimbursement rational indicates the following: “This charge was adjusted to comply with the rate
and rules of the contract indicated.”
Contractual Agreement provided for IBR, reflects”95%” of Billed Charges.

74. 97999 is a By Report code; a schedule allowance does not exist.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial Functional
Restoration Program, and a comparable procedure code does not exist.
CPT 97799 By Report Code is not subject to MPPR as there is no unit value or conversion factor associated with this By Report
Code.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this
section.
The Provider’s Usual and Customary Fee is presented on RFA dated 01/20/2016 as “$225.00/hour.”
Authorization for FRP dated 02/5/2016 signed by Claims Administrator reflects “Request: Additional 120 hours of NCFRP
(Functional Restoration Program), 6 hours daily –Monday through Thurs; 3 hours on Fridays (27 hours per week). Modified
Approval: additional 106 hours of NCFRP.” Reimbursement amount not reflected.
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
The aforementioned Authorization is contractual in nature.
Provider submitted claim for dates of service Monday 1/186 hours and Tuesday 1/196 hours= total 12
hours x $225.00 = $2,700 .00 x 95% = $2,565.00-$985.64= $1579.36.
Opportunity to dispute Eligibility communicated with the Claims Administrator on 5/5/2016; response not yet received.
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Unlisted Procedure Code
97799-86

75. 97799-86 Initial Evaluation - Functional
Restoration Evaluation
Provider seeking additional remuneration for Initial Evaluation - Functional Restoration Evaluation services, billed as Unlisted
Procedure Code 97799 -86, for date of service 12/23/2015.
The Claims Administrator’s reimbursement rational indicates the following: “charge was adjusted to comply with the rate and
rules of the contract indicated” and “charge exceeds the Official Medical Fee Schedule scheduled allowance.”
97999 is a By Report code; a schedule allowance does not exist.
Opportunity to dispute Eligibility communicated with the Claims Administrator on 04/20/2016; response not yet received.
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial Functional
Restoration Program Evaluation, and a comparable procedure code does not exist.
CPT 97799 By Report Code is not subject to MPPR as there is no unit value or conversion factor associated with this By Report
Code.
The Provider’s Usual and Customary Fee is presented on RFA dated 09/22/2015 as “$2,500.00.”
Authorization for Initial FRP Evaluation dated 09/25/2015 signed by Claims Administrator reflects “80” hours “approved.”
Reimbursement amount not reflected.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002
to add §5307.11: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety
Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule
adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250
of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those
in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this
section.

76. The aforementioned Authorization is contractual in nature; recommend reimbursement for 1 unit of 97799-86 representing date
of service 12/23/2015.
Partial two page Contractual Agreement provided for IBR, reflects”94%” lesser of OMFS or
Billed Charges.
Based on the aforementioned documentation and guidelines, additional reimbursement
is indicated for Unlisted Procedure Code 97799-86
97799-86
Functional
Restoration
Evaluation
EOR indicate The Claims
Administrator’s reimbursement was
based on “Physical Medicine” and
“negotiated rate.”
Provider seeking full remuneration for Functional Restoration Evaluation services, billed as Unlisted Procedure Code 97799-86,
for date of service 05/18/2015.
EOR indicate The Claims Administrator’s reimbursement was based on “Physical Medicine” and
“negotiated rate.”
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, a Functional Restoration
Program Evaluation, and a comparable procedure code does not exist. The ‘
Physical Medicine’ MPPR applied by the Claims Administrator does not apply in this circumstance
as a Functional Restoration Program is a comprehensive and multidisciplinary program which is
not strictly Physical Therapy Based
The Provider’s Usual and Customary Fee is presented on the Authorization Request dated 07/30/2013
as “225/hour”
Authorization for FRP dated 04/09/2015 signed by Claims Administrator does not indicate a procedure coded and does not
indicate agreement of charges but does agree to FRP, as such, the OMFS or contractual agreement dictates reimbursement for
97799-86.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
Recommend reimbursement for 1 unit of 97799-86 representing dates of service 06/26/2014.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a

77. contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum
reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care
facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this
section.
The aforementioned Authorization is contractual in nature.
Contractual Agreement Section 4.C (untitled page) indicates 95% of Eligible Billed Charges
for procedure codes of “no assigned value.”
Opportunity to Dispute communicated to Claims Administrator on 12/10/2015; response not yet received.
Based on the aforementioned documentation and guidelines, additional reimbursement is not indicated for Unlisted Procedure
Code 97799-86
97799-86 Claims Administrator denied FRP
services stating, “The billing has
exceeded the fee schedule
guidelines for payment of physical
therapy or physical medicine
treatment.”
Provider seeking full remuneration for Functional Restoration Initial Evaluation services, billed as Unlisted Procedure Code
97799-86, for date of service 01/26/2015 –01/30/2015.
Claims Administrator denied FRP services stating, “The billing has exceeded the fee schedule guidelines for payment of
physical therapy or physical medicine treatment.”
Functional Restoration Program service not in dispute.
Total Payment for FRP is in dispute.
Request for FRP states the Providers Usual and Customary fee of 160 hours @ $225 an hour; faxed to Claims Administrator by
Provider on 11/06/2014.
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization for Functional Restoration Program presented for IBR, dated February 11, 2015signed by Claims Administrator;
criteria for Modifier -86 met.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure

78. performed.”
Partial contractual agreement submitted for IBR indicates “95%” of “Eligible Billed Charges” for procedure codes with “no
assigned value.”
Opportunity to Dispute Edibility sent to Claims Administrator on 08/04/2015; response not yet received.
LC § 5307.11 : A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rates.
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, a Functional Restoration
Program; a CPT Code has yet to be formulated for this comprehensive program involving multiple specialties. As such, the
Physical Medicine Modality MPPR Reduction applied by the Claims Administrator is incorrect; the contractual agreement will
dictate the level of reimbursement pursuant to LC § 5307.11.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97799-86
97799-86 Claims Administrator denial
rational: “Documentation to
substantiate this charge was not
submitted or is insufficient to
accurately review this charge.”
Provider seeking full remuneration for Functional Restoration Evaluation services, billed as Unlisted Procedure Code 97799-86,
for date of service 03/10/2015–03/13/2015
Claims Administrator denial rational: “Documentation to substantiate this charge was not submitted or is insufficient to
accurately review this charge.”
Functional Restoration Program service not in dispute.
Payment for FRP is in dispute.
FRO Team Conference Report Week 5 documents services the multidisciplinary services of functional restoration program.
Provider submitted request for “Service: FRP (Multidisciplinary); Code: 97799, Modifier 86, Units 10(50 Hours)” reflects
Providers Usual and Customary Fee of $1000.00 dollars per day and $5000.00 per week.”
Utilization Review “Approved: 10 additional days (50 hours) of Functional Restoration Program”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”

79. §9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Authorization letter signed by Claims Administrator is contract in nature.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 97799-86.
97799-86 Claims Administrator denial
rational: “This is an unlisted
procedure. Please resubmit the bill
with a more descriptive code or
documentation.”
Provider seeking full remuneration for Functional Restoration Evaluation services, billed as Unlisted Procedure Code 97799-86,
for date of service 11/03/2014 –11/06/2014
Claims Administrator denial rational: “This is an unlisted procedure. Please resubmit the bill with a more descriptive code or
documentation.”
Functional Restoration Program service not in dispute.
Payment for FRP is in dispute.
Provider submitted request for “Service: FRP (Multidisciplinary); Code: 97799, Modifier 86, Units 10 (50 Hours)”
reflects Providers Usual and Customary Fee of $1000.00 dollars per day and $5000.00 per week.”
Utilization Review “Authorization 10 days of Functional Restoration Program” dated September 24, 2014.
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure , consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Authorization letter dated 09/24, 2014 and signed by Claims Administrator is contract in nature.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 97799-86

80. 97799-86
Functional
Restoration
Evaluation
EOR indicate services denied as
“not authorized by utilization and
review
Provider seeking full remuneration for Functional Restoration Evaluation services, billed as Unlisted Procedure Code 97799-86,
for date of service 06/12/2015.
EOR indicate services denied as “not authorized by utilization and review.”
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Functional
Restoration Program Evaluation, and a comparable procedure code does not exist. The 97750 code re
-assignment by the Claims Administrator does not adequately reflect the RVU’s relating to the comprehensive service of a FRP.
The Provider’s Usual and Customary Fee is presented on the Authorization Request dated 03/26/2015 as
$1000.00 per day/$5000.00 per week, 5 hours a day x 10 days.
Authorization for FRP dated 05/21/2015, Case # 323904, Start Date: 05/19/2015, End Date: 06/18/2015, x “50 hours.” signed
by Claims Administrator does not indicate a procedure coded and does not indicate agreement of charges but does agree to FRP,
as such, the OMFS or contractual agreement dictates reimbursement for 97799
-86.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
Recommend reimbursement for 1 unit of 97799-86 each representing dates of service 06/12/2015.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting
agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised
pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and
Safety Code, and a contracting agent, employer, or carrier contract
for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health
facility licensed pursuant to Section 1250 of the Health and Safety Code
shall not apply to the contracted reimbursement rates.Except as provided in subdivision (b) of Section 5307.1, the official medical
fee schedule shall establish maximum reimbursement rates for all medical services for injuries subject to this division provided
by a health care provider or health care facility licensed pursuant to Section
1250 of the Health and Safety Code other than those specified in contracts subject to this section.
The aforementioned Authorization is contractual in nature.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 10/27/2015; response not yet received.

81. Contractual Agreement not received for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for Unlisted Procedure Code 97799-86
for 1 Dayof FRP.
97799-86 Provider seeking full remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code 97799-86 for
dates of service 05/21/2015 –05/22/2015.
The Claims Administrator denied reimbursement with the following rational: “The defendant disputes whether the treatment is
reasonable or necessary.”
Opportunity to Dispute Eligibility communicated to Claims Administrator on 10/20/2015; response not yet received.
CMS 1500 reflects 97799 –86 @ $1,200.00 for each date of service.
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization for Functional Restoration Program presented for IBR, dated 05/05/2015 from Utilization Review
, indicates treatment “Functional restoration program 1-50 hours (97799); Request is certified.”
RFA dated 8/13/2014 reflects Provider ’s Usual and Customary fee as “$1,000.00” per day billed under 97799.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c)“In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
A Contractual Agreement for “BR” or unlisted codes without a relative value was not submitted, as such, the OMFS will be
utilized to determine reimbursement.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97799-86
as per OMFS to reflect the Provider’s Usual and Customary Fee.

82. 97799-86 The Claims Administrator denied
reimbursement with the following
rational: “The defendant disputes
whether the treatment is reasonable
or necessary
Provider seeking full remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code 97799-86 for
date of service 05/29/2015.
The Claims Administrator denied reimbursement with the following rational: “The defendant disputes whether the treatment is
reasonable or necessary.”
Opportunity to Dispute Eligibility communicated to Claims Administrator on 10/20/2015; response not yet received.
CMS 1500 reflects 97799 –86 @$1,200.00.
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization for Functional Restoration Program presented for IBR, dated 05/05/2015 from Utilization Review
, indicates treatment “Functional restoration program 1-50 hours (97799); Request is certified.”
RFA dated 8/13/2014 reflects Provider’s Usual and Customary fee as “1,000.00” per day billed under 97799.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
A Contractual Agreement for “BR” or unlisted codes without a relative value was not submitted, as such, the OMFS will be
utilized to determine reimbursement.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 97799-86 as per OMFS to reflect
the Provider’s Usual and Customary Fee.

83. 97799-86 The Claims Administrator denied
reimbursement as “not medically
necessary.”
Provider seeking remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code 97799-86 for date
of service 06/01/2015 –06/05/2015.
The Claims Administrator denied reimbursement as “not medically necessary.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization for Functional Restoration Program presented for IBR, dated 05/21/2015, reflecting “review of review, ” signed
by the Claims Administrator, indicates treatment as“ certified” meeting the criteria for Modifier
-86. Certification for “50” hours of FRP from “05/19/2015 –06/18/2015.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure
performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 10/13/2015; response not yet received.
Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Provider’s Usual and Customary Charge indicated on RFA dated 03/26/2015.
Contractual Agreement not submitted for IBR. 
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 97799-86.

84. 97799-86 EOR indicate services denied as
“not authorized by utilization and
review.”
Provider seeking full remuneration for Functional Restoration Evaluation services, billed as Unlisted Procedure Code 97799-86 ,
for date of service 06/08/2015-06/11/2015.
EOR indicate services denied as “not authorized by utilization and review.”
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Functional
Restoration Program Evaluation, and a comparable procedure code does not exist. The 97750 code re
-assignment by the Claims Administrator does not adequately reflect the RVU’s relating to the comprehensive service of a FRP.
The Provider’s Usual and Customary Fee is presented on the Authorization Request dated 03/26/2015 as $1000.00 per
day/$5000.00 per week, 5 hours a day x 10 days.
Authorization for FRP dated 05/21/2015, Case # 323904, Start Date: 05/19/2015, End Date: 06/18/2015, signed by Claims
Administrator does not indicate a procedure coded and does not indicate agreement of charges but does agree to FRP, as such, the
OMFS or contractual agreement dictates reimbursement for 97799-86.
Function al Restoration Program service is authorized meeting the criteria for Modifier -86.
Recommend reimbursement for 1 unit of 97799-86 each representing dates of service 06/08/2015 –06/11/2015.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11 : A health care
provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or
carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section
5307.1. When a health care provider or health facility licensed pursuant to Section
1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates
different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant
to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.Except as provided in
subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum reimbursement rates for all medical
services for injuries subject to this division provided by a health care provider or health care facility licensed pursuant to Section
1250 of the Health and Safety Code other than those specified in contracts subject to this section.
The aforementioned Authorization is contractual in nature.

85. Opportunity to Dispute Eligibility communicated to Claims Administrator on 10/27/2015; response not yet received.
Contractual Agreement not received for IBR.
Based on the aforementioned documentation and guidelines, additional reimbursement is not indicated for Unlisted Procedure
Code 97799-86 for 4 Days/24 hours of FRP.
97799-86
One Day
Multidisciplinary
Evaluation
The Claims Administrator denied
reimbursement as “not medically
necessary
Provider seeking $2,350.00 in remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code
97799-86 for date of service 07/02/2015.
The Claims Administrator denied reimbursement as “not medically necessary.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization for Functional Restoration Program presented for IBR, dated 05/11/2015, reflecting “ One Day Multidisciplinary
Evaluation,” signed by the Claims Administrator’s Physician Advisor, indicates treatment
As “approved,” meeting the criteria for Modifier -86.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 10/13/2015; response not yet received.
Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Provider’s Usual and Customary Charge indicated on RFA, referenced as “attached report,” dated 05/05/2015.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 97799-86

86. 97799-86 Provider seeking $4,000.00 in remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code
97799-86 for dates of service 05/26/2015, 05/27/2015, 05/28/2015 & 05/29/2015.
The Claims Administrator denied reimbursement as “insufficient documentation.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization for Functional Restoration Program presented for IBR, dated 06/12/2015, reflecting “10 additional days of
functional restoration program days 21-30/hours 101-150,” signed by the Claims Administrator, indicates treatment as“ certified,
” meeting the criteria for Modifier -86.
Submitted Report reflects a summary of the authorized six week (30 day) FRP program,
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c)“In determining the value of a By Report procedure, consideration may be given to the value assigned to a
Comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 10/13/2015; response not yet received.
Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Provider’s Usual and Customary Charge indicated on RFA , referenced as “attached report,”dated 05/06/2015.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 97799-86.

87. 97799-86
Initial
Functional
Restoration
Evaluation
services
Provider seeking full remuneration for Initial Functional Restoration Evaluation services, billed as Unlisted Procedure Code
97799-86, for date of service 05/07/2015.
EOR indicate The Claims Administrator’s reimbursement was based on Physical Medicine and contractual obligation.
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial
Functional Restoration Program Evaluation, and a comparable procedure code does not exist. The 97750 code re-assignment by
the Claims Administrator does not adequately reflect the RVU’s relating to the comprehensive service of a FRP.
The Provider’s Usual and Customary Fee is presented on the Authorization Request dated 04/07/2015 as “$2,500.00.”
Authorization for Initial FRP dated 04/13/2015 signed by Claims Administrator does not indicate a procedure coded and does
not indicate agreement of charges but does agree to Initial FRP evaluation and refers to original RFA of 04/07/2015.As such, the
OMFS or contractual agreement dictates reimbursement for 97799-86.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
Recommend reimbursement for 1 unit of 97799-86 representing dates of service 06/26/2014.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code,
and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule
adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rates.Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish
maximum reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or
health care facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject
to this section.
The aforementioned Authorization is contractual in nature.

88. Contractual Agreement under the heading" Compensation Provisions for Covered Services, "section "A1" indicates "60% " of
billed charges for procedures with no "defined amount."
97799-86 The Claims Administrator denied
reimbursement with the following
rational: “The defendant disputes
whether the treatment is reasonable
or necessary
Provider seeking full remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code 97799-86 x
3units, for dates of service 05/18/2015 –05/20/2015.
The Claims Administrator denied reimbursement with the following rational: “The defendant disputes whether the treatment is
reasonable or necessary.”
CMS 1500 reflects 97799 –86 once a day from 05/18/2015 –05/20/2015( 3days).
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization for Functional Restoration Program presented for IBR, dated 05/05/2015 from Utilization Review, indicates
treatment “Functional restoration program 1-50 hours (97799); Request is certified.”
Requested July 22, 2015 reflects Provider ’s Usual and Customary fee as “1,000.00” per day billed under 97799.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Contractual Agreement for BR, or unlisted codes without a relative value, not submitted from either party for IBR. As such,
OMFS utilized to determine payment.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97799-86
as per OMFS to reflect the Provider’s Usual and Customary Fee.

89. 97799-86 The Claims Administrator denied
reimbursement as “unlisted
procedure.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Request for Authorization for Multidisciplinary service using code 97799 with a daily rate of $1200.00 ($5000 per week)
submitted for review.
Authorization for Functional Restoration Program presented for IBR, dated August 20, 2015, reflecting “ Procedure/Treatment
Certified: 10 additional days for functional restoration program” by the Utilization Review, indicates treatment as “certified ”
meeting the criteria
for Modifier -86.
Report submitted documents services performed on dates of service 9/9, 9/10 and 9/11/2015.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report ”
CCR §9789.12.4 (c)“In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as
practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement
or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 02/26/2016; response not yet received.
Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 97799-86.
97799-86 The Claims Administrator denied
reimbursement as “Preauthorization
is required for this service or
procedure.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Request for Authorization for Multidisciplinary service using code 97799 with a daily rate of $1200.00 ($5000 per week)
submitted for review.
Authorization for Functional Restoration Program presented for IBR, dated September 17, 2015, reflecting
“Procedure/Treatment Certified:
Hours 76-150 of functional restoration program” by the Utilization Review, indicates treatment as “certified,” meeting the criteria
for Modifier -86.
Report submitted documents services performed on dates of service 9/24and 9/25/2015.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report”
CCR §9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a

90. comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 02/26/2016; response not yet received.
Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 97799-86.
97799-86
Initial valuation”
regarding
a “Functional
Restoration Program
Claims Administrator
reimbursement rational -as reflected
on EOR as follows: “Charges
reduced in accordance with base
allowance per the applicable fee
schedule.”
Modifier -86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial Functional
Restoration Program Evaluation, and a comparable procedure code does not exist.
CPT 97799 By Report (BR) Code is not subject to MPPR as there is no unit value or conversion factor associated with this By
Report Code.
The Provider’s Usual and Customary Fee is presented on the RFA dated 06/22/2015, for “$2,500.00” for an “Initial Evaluation ”
regarding a “Functional Restoration Program.”
Authorization dated 06/24/2015 signed by Claims Administrator UR representative indicates“ certification,”And does not
indicate a modification of charges. Functional Restoration Program service is authorized; criteria for Modifier -86.
Payment reflected on EOR indicates authorization for Initial FRP Services is not in dispute; full payment for billed Initial FRP
services is the subject of dispute.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11 : 5307.11. A health
care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant
to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates. Except as provided
in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum reimbursement rates for all
medical services for injuries subject to this division provided by a health care provider or health care facility licensed pursuant to
Section 1250 of the Health and Safety Code other than those specified in contracts subject to this section.
Partial one page Contractual Agreement provided for IBR, reflects procedure codes with no assigned value reimbursed at
“95%” of billed charges.
CPT 97799 is a By Report Code without a comparable procedure, without a ‘unit value’ or conversation factor. As such, the
contractual reimbursement rate defaults to the ‘Unlisted Procedure,’ reimbursement contract terms as per
LC §5307.11 “the medical fee schedule shall not apply to the contracted reimbursement rates.”
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Unlisted Procedure Code

91. 97799-86.
97799-86
Initial
Interdisciplinary
Evaluation
The Claims Administrator based reimbursement on the “rate and rules of the contract indicated.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rule
Certification for an initial evaluation for functional restoration program from Claims Administrator showing “Approved”
submitted for review.
EOR’s indicate services “authorized,” meeting the criteria for modifier -86.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed. ”The Physical
Therapy reimbursement rational assigned by the Claims Administrator is not a
comparable comparison for this type of Program.
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive multispecialty
program. As such, a contractual agreement or the OMFS will dictate the level of reimbursement.
Submitted Contractual Agreement for Workmens’ Compensation “95%” for which there is no assigned value.
CCR § 5307.11 : A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for 97799-86
at contractual rate.

92. 97799-86 Provider seeking remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code 97799-86 for
dates of service 08/12/2015 –09/04/2015.
The Claims Administrator denied reimbursement as “unlisted procedure.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Request for Authorization for Multidisciplinary service using code 97799 with a daily rate of $1200.00 ($5000 per week)
submitted for review.
Authorization for Pain Management Evaluation presented for IBR, dated August 20, 2015, reflecting “ Procedural/Treatment
Certified: 10 additional days for functional restoration program ” by the Utilization Review,indicates treatment as“ certified,”
meeting the criteria for Modifier -86.
Report submitted documents services performed on date of service 8/31, 9/3, 9/4, 9/9, 9/10 and 9/11/15.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR §9789.12.4 (c)“In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous co de should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this omprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 02/26/2016; response not yet received.
Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 97799-86

93. 97799-86 Provider seeking remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code 97799-86 for
dates of service 09/14/2015–09/23/2015.
The Claims Administrator denied reimbursement as “Preauthorization is required for this service or procedure.”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Request for Authorization for Multidisciplinary service using code 97799 with a daily rate of $1200.00 ($5000 per week)
submitted for review.
Authorization for Functional Restoration Program presented for IBR, dated September 17, 2015, reflecting “
hours 76-150 of functional restoration program” by the Utilization Review , indicates treatment as “certified,” meeting the criteria
for Modifier -86.
Report submitted documents services performed on dates of service 9/14, 9/21, 9/23, 9/24 and 9/25/2015.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report”
CCR §9789.12.4 (c)“In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799
or, more specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program.
As such, a contractual agreement or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 02/26/2016; response not yet received.
Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Contractual Agreement not submitted for IBR.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 97799-86.

94. 97799-86 The Claims Administrator’s
reimbursement rational indicates
“pre-negotiated agreement” and
“contract” indicated.
Functional Restoration Evaluation services, billed as Unlisted Procedure Code 97799-86 , for date of service 10/26/2015 –
10/28/2016; 3 days of FRP
The Claims Administrator’s reimbursement rational indicates “pre-negotiated agreement” and “contract” indicated.
Modifier-86: OMFS “This Modifier is used when prior authorization was received for services that exceed OMFS ground
rules.”
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance listed under the OMFS for the billed procedure code 97799 or, more specifically, an Initial
Functional Restoration Program Evaluation, and a comparable procedure code does not exist.
CPT 97799 By Report Code is not subject to MPPR as there is no unit value or conversion factor associated with this By Report
Code.
The Provider’s Usual and Customary Fee is presented on RFA dated 08/10/2015 as “$225.00” per hours.
Authorization for FRP dated 08/12/2015 signed by Claims Administrator reflects “80” hours “approved.” Reimbursement
amount not reflected.
Functional Restoration Program service is authorized meeting the criteria for Modifier -86.
Documentation indicates 27 hours, Week 5; 53 hours less than authorized ’80’ hours.
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11 : 5307.11. A health
care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant
to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety
Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the
medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety
Code shall not apply to the contracted
reimbursement rates.Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish
maximum reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or
health care facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject
to this section.
The aforementioned Authorization is contractual in nature.

95. Partial two page Contractual Agreement provided for IBR, reflects “95% of Eligible Billed Charges.”
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Unlisted Procedure Code
97799-86
97799-86 (27 units) Provider dissatisfied with reimbursement of code 97799-86
Based on review of the Physician’s Initial Evaluation, procedure code 97799-86 is substantiated as the Provider documented
services performed and Provider’s Usual and Customary charge.
The Physician Evaluation details the injured worker’s medical history, current medications, physical examination including
functional strength, range of motion, function movement and lifting, dynamic posture and stabilization, psychological evaluation,
treatment plan and a formal request for authorization, a thorough evaluation was performed on this injured worker
Documents reviewed included a Request for Medical Treatment for 80 hours of NCFRP at $225.00 per hour.
Utilization Review Notice indicated certification for 80 hours of Functional Restoration Program 02
/26/2014 to 04/26/2014
PPO Contract was reviewed which shows “Medical treatment shall be reimbursed at ninety-five
percent (95%) of the Official Medical Fee Schedule (“OMFS”) or billed charges, whichever is less.
97799-86. The Claims Administrator denied Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.

96. reimbursement as “unlisted
procedure.”
Request for Authorization for Multidisciplinary service using code 97799 submitted for review.
Authorization for Pain Management Evaluation presented for IBR, dated April 14, 2015, reflecting “1 day of Pain Management
Evaluation,” by the
Utilization Review, indicates treatment as “certified, ” meeting the criteria for Modifier -86.
Report submitted documents services performed on date of service 7/6/2015.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
CCR § 9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 97799 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 11/19/2015; response not yet received.
 Unless otherwise indicated by a Contractual Agreement, “By Report” codes are reimbursable at the Provider’s Usual and
Customary Charge.
Contractual Agreement not submitted for IBR.
97799-86x 5 Claims Administrator denied code
for three dates of service indicating
on the Explanation of Review
“Unlisted/BR svc not documented.
Payment requires documentation
explaining the service. See OMFS
instructions for Procedures without
Unit Values.”
Provider is dissatisfied with denial of code 97799-86 x 5.
Claims Administrator denied code for three dates of service indicating on the Explanation of Review “Unlisted/BR svc not
documented. Payment requires documentation explaining the service. See OMFS instructions for Procedures without Unit
Values.”
Documentation received included a Functional Restoration Program Authorization Request, authorization and Reimbursement
Agreement which states a request for additional 10 days/50 hours of OCPWC’s FRP (5 hours per day) at $1000 per day using
CPT code 99499.
Letter dated May 5, 2014 from Claims Administrator’s Utilization Review Department approved Outpatient Functional
Restoration Program for 10 days (50 hrs.) for low back.
Reconsideration Request with a correct claim was submitted to Claims Administrator stating “Unlisted CPT code, 99499, has
been corrected to 97799-86 to better reflect services rendered in the Functional Restoration Program (FRP).”
Provider submitted an FRP Team Conference Report documenting all the procedures performed with the injured worker for the
three days for the Functional Restoration Program.
Based on the information reviewed, reimbursement for code 97799 x 5 is warranted.
PPO contract was received and an 8% discount is to be applied

97. 97813, 97814, 97110
Claims Administrator denied codes
with rationale “
Many therapy services are time-
based codes, i.e., multiple units may
be billed for a single procedure .
The MPPR applies to the Practice
Expense (“PE”) payment when
more than one unit or procedure is
provided to the same patient on the
same day, i.e., the MPPR applies to
multiple units as well as multiple
procedures. Full payment is made
for the unit or procedure with the
highest PE payment. Full payment
is made for the work and
malpractice components and 50
percent payment is made for the PE
for subsequent units and
procedures, furnished to the same
patient on the same day
Provider seeking remuneration for codes 97813, 97814and 97110 on date of service 3/19/2015
Claims Administrator denied codes with rationale “
Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure . The MPPR applies to the
Practice Expense (“PE”) payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the
MPPR applies to multiple units as well as multiple procedures. Full payment is made for the unit or procedure with the highest
PE payment. Full payment is made for the work and malpractice components and 50 percent payment is made for the PE for
subsequent units and procedures, furnished to the same patient on the same day.
The MPPR applies to acupuncture codes and chiropractic manipulation codes and to the procedures listed in the “Separately
Payable Always Therapy Services Subject to the Multiple Procedure Payment Reduction (MPPR)” file of the Medicare Physician
Fee Schedule Final Rule. The listed procedures will also have a Multiple Procedure value of “5” on the National Physician Fee
Schedule Relative Value File. When billing for physical medicine modality, procedure, or acupuncture codes, no more than 60
minutes on the same visit.
CMS 1500 documents:1.1 unit of 97813, Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of
personal one-on-one contact with the patient 2. 2 units of 97814, Acupuncture, 1 or more needles; with electrical stimulation,
each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in
addition to code for primary procedure) 3.1 unit of 97110, Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic
exercises to develop strength and endurance, range of motion and flexibility.
Total time for acupuncture on date of service 3/19/2015 is 60 minutes.
Provider’s Treatment Sheet documents 15 minutes of 97813, 30 minutes of 97814 and 15 minutes of 97110 and is signed by the
injured worker.
Based on aforementioned and guidelines, reimbursement of 97813, 97814 and 97110 is
warranted

98. 99199 Initial, subsequent and final EOR’s
reflect the Claims Administrator
denied reimbursement with the
following rational: “Service has a
relative value of zero”

RFA HELP treatment program Authorized by Claims Administrator pm 10/13/2015, Review ID# 1001215261001.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice
expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 99199 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive interdisciplinary
program. As such, a
contractual agreement or the OMFS dictate s the level of reimbursement.
Authorization 10/13/2015, is contractual in nature. Since the “treatment” was authorized, the reimbursement defaults to the
existing contractual agreement pursuant to
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11: 5307.11. A health care
provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or
carrier may
contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section 5307.1. When a
health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier
contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or
health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement
rates.
Partial Contractual Agreement Received. Carve out portion of the contract reflects the following regarding CPT 99199:
“CPT 99199 Functional Restoration Program Daily rate 10% discount from billed charges, not to exceed $1,000.00 per day.”
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 99199
99199 Initial, subsequent and final EOR’s
reflect the Claims Administrator
denied reimbursement with the
following rational: “Service has a
relative value of zero”
Functional Restoration Program services, billed as Unlisted Procedure Code 99199 for date of service 11/09/2015
–11/11/2015, 3 days.
Initial, subsequent and final EOR’s reflect the Claims Administrator denied reimbursement with the following rational:
“Service has a relative value of zero”
RFA HELP treatment program Authorized by Claims Administrator pm 10/13/2015, Review ID# 1001208794001.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a

99. comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 99199 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive
Interdisciplinary program. As such, a contractual agreement or the OMFS dictates the level of reimbursement.
Authorization 10/13/2015, is contractual in nature. Since the “treatment” was authorized, the reimbursement defaults to the
existing contractual agreement pursuant to
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11: 5307.11. A health care
provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or
carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section
5307.1. When a health care provider or health facility licensed pursuant
to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates
different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant
to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Partial Contractual Agreement Received. Carve out portion of the contract reflects the following regarding CPT 99199:
“CPT 99199 Functional Restoration Program Daily rate 10% discount from billed charges, not to exceed $1,000.00 per day.”
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 99199.
99204 and WC007 The Claims Administrator denied
services in full due to “absence of
pre-certification.”
Provider seeking remuneration for 99204 New Patient Evaluation Services and WC007-30 (Consultation
Reports Requested by AME or QME), for date of service 01/21/2015.
The Claims Administrator denied services in full due to “absence of pre-certification.”
Submitted referral from AME (referring Provider) to Provider indicates the following request:
EMG/NCV and Neurodiagnostic testing and Consultation Report of Bilateral Lower Ext.
CCR § 9789.12.12 (c)(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.
CMS 1500 reflects 99204 and WC007; Modifier -30 appended to WC007.
EMG/NCV CPT codes not reflected
2nd EOR reflects “99070” Supplies and Materials denied as “previously reviewed.”
Submitted CMS 1500 does not indicate 99070.
Referring provider AME status verified via written request to AME from Legal Parties.
AME authorized to perform tests AME has deemed “reasonably necessary to properly evaluate” applicant.

100. The determination of an Evaluation and Management service for New Patients require All three key
components in the following areas (AMA CPT 1995/1997):
1)History: Chief Complaint, History of Present Illness, Review of Systems (Inventory of Body Systems), Past Family and Social
History.
2)Examination: “The 1995 documentation guidelines state that the medical record for a general multi-system examination should
include findings about eight or more organ systems.”
3)Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a
management option, which is determined by considering the following factors:
a.The number of possible diagnoses and/or the number of management options that must be considered;
b.The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed,
and analyzed; and
c.The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s
presenting problem(s), the diagnostic procedure(s), and/or the possible management options.To determine the level of service in
a given component of an E&M, the data must “meet or exceed” the elements required.
1995/1997 Evaluation and Management Levels/Elements (History / Exam / Medical Decision Making), Established Patient:
99202: Exp. Problem Focused / Exp. Problem Focused / Straight Forward
99203: Detailed / Detailed Exam / Low Complexity
99204: Comprehensive / Comprehensive Exam / Moderate Complexity
99205: Comprehensive / Comprehensive Exam/ High Complexity
Time: In the case where counseling and/or coordination of care dominates (more than 50%)of the physician/patient and/or
family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility),
time is considered the key or controlling factor to qualify for a particular level of E/M services. The total length of time of the
encounter (faced-to-face) should be documented and the record should describe the counseling and/or activities to coordinate
care.
Abstracted information for date of service 01/21/2015 revealed the following service:
History:
HPI: Extended
ROS: Extended
Other History: Complete
Extended/ Extended / Complete = Detailed History (99203)
Exam:
Detailed extended of affected area / organ system + related/ symptomatic areas (99203)
Medical Decision Making: -
Presenting Problems/Diagnosis = Limited
oReferred for EMG/NCV and Consultation for Bilateral Lower Extremities
Complexity of data= Limited
o“No Available Medical Records”
oEMG Report
Risk: Low
oRecommendations made for AME Review.
Detailed / Detailed/ Low = Low Complexity Medical Decision Making (99203)
New Patient E & M must meetall three key components:
Detailed / Detailed /Low= 99203Time Factor for date of service:

101. Not Indicated
WC007 -$38.68 for first page, $23.80 each additional page. Maximum of six pages absent mutual agreement ($157.68).
Opportunity to Dispute Eligibility communicated with the Claims Administrator on 05/23/2016; response not yet received.
Contractual Agreement not submitted for IBR; OMFS utilized.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for WC007-30
and 99203 and is not indicated for 99204
99204 and WC007 The Claims Administrator denied
service in full stating, “Claim
Settled, no open medical treatment
allowed
Provider seeking remuneration for 99204 New Patient Evaluation service and WC007 QME/AME Requested Consultation
Reports, for date of service 12/19/2014.
.”
Communication from Claims Administrator, dated October 20, 2014, to referring Provider reflects status as “Agreed Medical
Examiner,” requested by Claims Administrator to perform Med-Legal Evaluation and“ this letter constitutes your authority to
perform all tests which you believe are necessary.”
Submitted referral from AME (referring Provider) to Provider indicates the following stamped request:
EMG/NCV and Neurodiagnostic testing and Consultation Report of Bilateral Upper Ext.
Although the referral from the AME is stamped to include “and Consultation and Report,” only the EMG/NCV testing , in
accordance with the AME acknowledgment letter, was authorized by the Claims Administrator.
Referral for Consultation not indicated on the AME request from the Claims Administrator.
Copies of the actual EMG/NCV studies were not submitted for IBR and a CPT Code for the approved testing cannot be
extrapolated from the report. Although EMG needle services are addressed in the dictated report, the testing results are
necessary to ensure full PC/TC RVU compliance in accordance with a correlating EMG/NCV CPT code.
Based on the aforementioned, reimbursement is warranted for WC007

102. 99204 and WC007-
30
The Claims Administrator denied
service as follows:
99204 “included in the value of
another service,”
WC007 “report does not appear to
be requested...”
Provider seeking remuneration for 99204 New Patient Evaluation and WC007 –30 Consultation Reports, performed
on 10/08/2014.
The Claims Administrator denied service as follows:
99204 “included in the value of another service,”
WC007 “report does not appear to be requested...”
Contractual Agreement not presented for IBR
Request by Legal Parties, dated 08/28/2014, confirms request to Referring MD for AME Evaluation.
Authorization for “EMG/NCV and Neurodiagnostic Testing and Consultation Report of Bilateral Upper Extremity, ”dated
09/29/2014 , from Referring M.D.to Provider.
The determination of an Evaluation and Management service for New Patients require all three key components in
the following areas (CMS.Gov):
1. History : Chief Complaint, History of Present Illness, Review of Systems (Inventory of Body Systems), Past Family and
Social History.
2. Examination: All elements in a general multi system examination, or complete examination of a single organ system and
other symptomatic or related body area(s) or organ system(s)
3. Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a
management option, which is determined by considering the following factors:
a.The number of possible diagnoses and/or the number of management options that must be considered;
b.The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed,
and analyzed; and
c.The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s
presenting problem(s), the diagnostic procedure(s), and/or the possible management options.
1995/1997 Evaluation and Management Levels/Elements: History / Exam / Medical Decision Making, New Patient, All Three

103. Components Must Be Met (CMS.Gov):
99202: Problem Focused / Problem Focused / Straight Forward
99203: Expanded Problem Focused / Expanded Problem Focused / Low Complexity
99204:Detailed History / Detailed Exam / Moderate Complexity
99205 Comprehensive History/ Comprehensive Exam/High Complexity
Time:In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or
family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility),
time is considered the key or controlling factor to qualify for a particular level of E/M services. The total length of time of the
encounter (faced-to-face) should be documented and the record should describe the counseling and/or activities to coordinate
care.
Abstracted information from 10/08/2014 date of service indicates the following 99202 level:
Detailed History/ Detailed Exam / Straight Forward Medical Decision Making (“deferred to patients primary treating
physician.”)
Total visit time not indicated on 10/08/2014 exam.
Abstracted elements from Date of Service 10/08/2014, Exam Elements did not support a New Patient Level 4 Service.
Recommended reimbursement for supported service 99202.
WC007 - $38.68 for first page - maximum of six pages absent mutual agreement ($157.68)
WC007-31 reimbursement warranted as per aforementioned 09/29/2014 request.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 99202 and WC007-31
and is not supported for 99204.
99205
-
25, 99354
-
59, 99355
-
59, and 96101
-
IB
R Final Determination
OVERTURN
, Physician
Services
CB16
-
00005

104. 59 90
Page
3
of
5
ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE
IN DISPUTE
:
Provide
r seeking remuneration for 992
05 New Patient Evaluation
and
99354 Prolonged Ser
vices with Face
-
to
-
Face Contact
1
st
hour,
add
-
on code 99355
each additional 30 min, and
9
6101
Physiological
Testing
submitt
ed for date of service
12/
2
1/2015
.

The Claims Administrator
’s
d
own
-

105. coded 99205 to 99203 based on submitted
documentation
not
me
eting
“
3 ke
y
”
components.

Contractual Agreement Not Received for IBR.

The determination of an Evaluation and Management service for
New
Patients require
All
three
key
components
or time
-
component
in the
following areas (AMA CPT 1995
/1997
):
1)
History
: Chief Complaint, History of Present Illness, Review of Systems
(Inventory
of Body Systems), Past Family and Social History.
2)
Examination
: “The 1995 documentation guidelines state that the medical record for a
general multi
-
system examination should include findings about eight or more organ
systems.
”
3)
Medical Decision Making Medical
decision making refers to the complexity of
establishing a diagnosis and/or selecting a management option, which is determined

106. by considering the following factors:
a.
The number of possible diagnoses and/or the number of management options
that must be cons
idered;
b.
The amount and/or complexity of medical records, diagnostic tests, and/or
other information that must be obtained, reviewed, and analyzed; and
c.
The risk of significant complications, morbidity, and/or mortality as well as
comorbidities associated wi
th the patient’s presenting problem(s), the
diagnostic procedure(s), and/or the possible management options.

To determine the level of service in a given
component
of an E&M, the
data
must “
meet
or exceed
” the elements required.

1995
/1997
Evaluation and M
anagement Levels/
Elements
(History / Exam / Medical
Decision Making), Established Patient:

99202: Exp. Problem Focused /
Exp.
Problem Focused
/ Straight Forward

99203: Detailed / Detailed Exam /
Low Complexity

99204: Comprehensive / Comprehensive Exam / Moderate Complexity

99205:
Comprehensive / Comprehensive Exam/ High Complexity


107. High Risk = Presenting Problems: One or more chronic illnesses with
severe exacerbation, progression, or side effects of treatment.
Acute
or chronic illnesses or injuries that pose a threat to life or bodily
function, eg, multiple trauma, acute MI, pulmonary embolus, severe
respiratory distress, progressive severe rheumatoid arthritis,
psychiatric illness with potential threat to sel
f or others, peritonitis,
acute renal failure. An abrupt change in neurologic status, eg, seizure,
TIA, weakness, sensory loss
IB
R Final Determination
OVERTURN
, Physician
Services
CB16
-
00005
90
Page
4
of
5

Diagnostic Procedure(s) Ordered: Cardiovascular imaging studies with
contrast with identified risk factors. Cardiac electrophysio
logical tests
Diagnostic Endoscopies with identified risk factors Discography

Management Options: Elective major surgery (open, percutaneous or
endoscopic) with identified risk factors Emergency major surgery
(open, percutaneous or endoscopic). Parenteral
controlled substances.
Drug therapy requiring intensive monitoring for toxicity Decision not
to resuscitate or to de
-
escalate care because of poor prognosis

Face
-
to
-
Face Time Requirement, 60 minutes.


108. Time:
In the case where counseling and/or coordination of care dominates (more than 50%)
of the physician/patient and/or family encounter (face
-
to
-
face time in the office or other
outpatient setting or floor/unit time in the hospital or nursing facility), time i
s considered the
key or controlling factor to qualify for a particular level of E/M services. The total length of
time of the encounter (faced
-
to
-
face) should be documented and
the record should
describe
the counseling and/or activities to coordinate care.

Abstracted information for date of service
12/
2
1
/
2015
revealed
a time
-
driven
P
sychological Consultation.
o
P
age 1 of Consultation Report, the
Provider
indicates
consultation interview
lasted a minimum of 105 minutes.
”

99205
time c
omponent is 60 minutes.
o

109. The
documented
total time over the 60 minute time frame
for 99205
is 45
minutes
.
o
1 unit is indicated for
99354
, Prolonged
Services to cover the 45 additional face to
face minutes
.

Add
-
On code 99355 i
s not indicated
as the total time is
represented
in full by CPT
99205
and 99354.

9
6101 Denied by the Claims Administrator
indicating
“
documentation does not indicate
the service was performed.
”
Page
5 and
6
of the
Psychological Consultation, the Provider indicates
Psychological
Tests
were
administered
with “
Computerized
Scoring

110. ”
was
utilized
“
to
generate
a
report
”
for
the Injured Worker
“
based o
n her
Reponses
and
interpretive
language
”
and
results
were
“
paraphrased
”
in the report.

CPT
96101
Psychological testing (includes psychodiagnostic assessment of em
otionality,
intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per
hour of the psychologist's or physician's time, both face
-
to
-
face time administering tests to
the patient and time interpreting these test results and pr
eparing the report
. The
Consultation
Report
indicates
a scoring
and report performed by a computer. As such,

111. 96101 is not indicated
.
Reimbursement
is
recommended
for
documented service
96103
Psychological testing
(includes psychodiagnostic assessment of emotionality, intellectual
abilities, personality and psychopathology, eg, mmpi),
administered by a computer
, with
qualified health care professional interpretation and report
, x 1 unit.

Based on the aforementioned documentation an
d guidelines, reimb
ursement is
indicated for
99205,
99354 and 96103
and is not indicated for 9
9355 and 96101
.

112. 99205 The Claims Administrator’s denied
service as not authorized
Provider seeking remuneration for 99205 New Patient Evaluation and Management Service performed on
09/14/2015.
The Claims Administrator’s denied service as not authorized
Communication dated July 14, 2015 and signed by Claims Administrator states “Per the Utilization Review enforcement
regulations (CCR §9792.11 –9792.15), this letter will serve as written authorization for injured worker to been seen by Provider,
for consultation regarding the patient ’s injury to her
cervical and lumbar spine”
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Documentation dated July 14, 2015 is contract in nature.
Provider’s Initial Orthopedic Consultation Report documents consultation for injured worker’s injury to the cervical and lumbar
spine.
Opportunity to Dispute communicated to Claims Administrator on 3/1/2016; response not yet received.
Based on the aforementioned documentation and guidelines, reimbursement for Evaluation and Management 99205 is
warranted.

113. 99205 Claims Administrator denied code
indicating not authorized
Provider seeking remuneration of 99205 on date of service 09/26/2014.
Claims Administrator denied code indicating not authorized.
Communication dated September 10, 2014 certified spine surgeon consult with Provider signed by Claims Administrator.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Provider’s report documents services by Provider on date of service 9/26/2014.
Documentation dated September 10, 2014 is contract in nature. Therefore, reimbursement of 99205 is warranted.
99205 The Claims Administrator’s denied
service as not authorized

Communication dated July 14, 2015 and signed by Claims Administrator states “Per the Utilization Review enforcement
regulations (CCR
§9792.11–9792.15), this letter will serve as written authorization for injured worker to been seen by Provider, for consultation
regarding the
patient’s injury to her cervical and lumbar spine”
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to
Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code,
and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the

114. medical fee schedule for
that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the
contracted reimbursement rates.
Documentation dated July 14, 2015 is contract in nature.
Provider’s Initial Orthopedic Consultation Report documents consultation for injured worker’s injury to the cervical and lumbar
spine.
Opportunity to Dispute communicated to Claims Administrator on 3/1/2016; response not yet received.
99205-25 The Claims Administrator’s denied
service as not authorized
Provider seeking remuneration for 99205 New Patient Evaluation and Management Service performed on 05/28/2015.
The Claims Administrator’s denied service as not authorized
The Provider is the Primary Treating Physician. Status verified by 04/15/2015 letter to Provider from Claims Administrator.
Primary Treating Physician’s Initial Report documents the Provider’s initial visit with the injured worker.
Opportunity to Dispute communicated to Claims Administrator on 11/16/2015 ; response not yet received.
Based on the aforementioned documentation and guidelines, reimbursement for Evaluation and Management
99205 iswarranted
.
99205-25,
99354
CPT code 99205 was down coded to 99202 and 99354 was denied by the Claim Administrator
.The Official Medical Fee Schedule and CPT 2014Edition were reviewed .
Based on review of the medical record documentation the services satisfy the requirements for
Alevel 99203 Consultation. This service has a typical time of 30 minutes.
Based on the Psychiatric Consultation Report for service date 4/15/14 the disputed E/M code 99205
does not meet documentation requirements for a Comprehensive History and Exam. A Comprehensive History must include 10
or more Review of Systems. A Comprehensive Psychiatric exam is also required.
This would be separate and in addition to the components documented in the service 96101 , Psychological Testing. The Decision
making is “High” as per documentation. A Consultation requires
that all three key components of History, Exam and Decision Making meet or exceed the level of service.
The prolonged time consulting with the patient exceeds the typical time of 30 minutes for a
99203 Consultation. Allow reimbursement of CPT code 99354 for additional time spent face

115. to face in excess of 99203. The Provider states he spent from 2:00 to 4:00 face to face with
the patient during the Consultation.
99214 The Claims Administrator denied
reimbursement due to “billing E/M
codes is limited to physicians,
physician assistants or nurse
practitioners, therefore this service
is not reimbursed”
Provider is the Primary Treating Physician
As the designated Primary Treating Physician, authorization for follow-up visits are not required.
Claims Administrator reimbursed WC002 –Primary Treating Physician’s Progress Report (PR-2)
, which was billed along with 99214 on the CMS 1500 form for the same date of service
A Contractual Agreement was not submitted for IBR.
Opportunity to Dispute communicated to Claims Administrator on 01/06/2016; response not yet received.
Based on the aforementioned documentation and guidelines, reimbursement for Evaluation and Management 99214is warranted
99214 and WC002 Letter to Provider from The Claims
Administrator dated 7/31/2015 &
08/15/2015 denied services with the
following rational: “The provider
was not cert5ified/eligible to be
paid for this procedure/service on
this date of service.”
Provider seeking additional remuneration for 99214 Established Patient and WC002 Primary Treating Physician
Progress Report for date of service 06/26/2015.
Letter to Provider from The Claims Administrator dated 7/31/2015 & 08/15/2015 denied services with the following rational:
“The provider was not cert5ified/eligible to be paid for this procedure/service on this date of service.”
No indication that diagnosis or body parts is reason for denial.
Service Codes not referenced in denial letter.
CMS 1500 form reflects amount and date of services denied by Claims Administrator
July 31, 2012 communication from Claims Administrator identifies the Provider as the “Primary Treating Physician” for
Injured Worker.
Primary Treating Physician Office Visits for ongoing medical care do not require Prior Authorization.
06/26/2015 Visit documentation indicates 06/2014 QME report reviewed by Provider noting that the Injured Worker has not yet
reached Permanent and Stationary Status regarding “left shoulder/elbow.”
06/25/2015 indicates Injured Worker seen form “left upper extremity pain.”
CMS 1500 Primary and Secondary Diagnoses consistent with QME reference.
Unless otherwise indicated in a Contractual Agreement, WC002 reports are reimbursable when an Injured Worker is seen for
ongoing medical treatment and the report meets reporting guidelines.

116. 99214 service criteria met in the form of report reflecting that the Provider addressed Injured Worker’s “left upper extremity
pain,” initiated RFA for physical therapy, and discussed treatment options.
Contractual Agreement not received for IBR.
§9785 Reporting Duties of the Primary Treating Physician. “...If a narrative report is used, it must be entitled “
Primary Treating Physician's Progress Report” in bold-faced type , must indicate clearly the reason the report is being submitted,
and must contain the same information using the same subject headings in the same order as
Form PR-2.”
Submitted visit documentation does meet the criteria of a PR-2 report as indicated in § 9785.
Opportunity do Dispute communicated to Claims Administrator on 09/24/2015; response not yet received.
Based on the aforementioned guidelines, reimbursement is warranted for 99214 and is not supported for
WC002.
99214 and WC002 The Claims Administrator denied
reimbursement due to “Duplicate
claim/service”
Provider seeking remuneration for 99214 Evaluation and Management and WC002 Primary Treating Physician Report submitted
for date of service 05/13/2015.
The Claims Administrator denied reimbursement due to “Duplicate claim/service”
The Claims Administrator is not disputing Provider is the Primary Treating Physician.
As the designated Primary Treating Physician, authorization for follow-up visits are not required.
Unless stipulated by A Contractual Agreement, WC002 California Specific Report is reimbursable when on
-going treatment of an accepted injury is rendered. The PR-2 report reflects treatment for established injury.
Contractual Agreement not submitted for IBR.
Opportunity to Dispute communicated to Claims Administrator on 10/27/2015; response not yet received.
Based on the aforementioned documentation and guidelines, reimbursement for Evaluation and Management
99214& WC002 is warranted

117. 99214 and WC002 The Claims Administrator denied
the service based on unauthorized
service.
Provider seeking remuneration for 99214 Evaluation and Management and WC002 Primary Treating Physician PR
-2 Progress Report provided on 04/28/2015.
The Claims Administrator denied the service based on unauthorized service.
Communication from the claimant’s attorney to the Claims Administrator on September 7 , 2012 indicates the Provider was
“chosen” as the “new treating physician” for Injured Worker. As such, authorization for an office visit related to accepted body
parts is not necessary.
PR-2 submitted documents services performed on date of service 4/28/2015.
Based on the aforementioned documentation and guidelines, reimbursement for Evaluation and Management Level
99214 is recommended.
WC002 PR-2 reports are reimbursable in addition to an Evaluation and Management Service in accordance with Title 8, CCR
§9789.14 as the Provider treated Injured Worker for the industrial injury.
Contractual Agreement not available for IBR.
99215 and WC002 The Claims Administrator’s denied
reimbursement due to unauthorized
services
Provider seeking remuneration for 99215 Evaluation and Management and WC002 Primary Treating Physician Report submitted
for date of service 06/03/2015.
The Claims Administrator’s denied reimbursement due to unauthorized services.
The Provider is the Primary Treating Physician. Status verified by January 17, 2014 letter to Claims Administrator
from Applicant’s Attorney.

118. As the designated Primary Treating Physician, authorization for follow-up visits are not required.
Title 8 Section 9785: (8) when continuing medical treatment is provided, a progress report shall be made no later than forty-five
days from the last report of any type under this section even if no event described in paragraphs (1) to (7) has occurred. If an
examination has occurred, the report shall be signed and transmitted within 20 days of the examination. Except for a response to a
request for information made pursuant to subdivision (f)(7), reports required under this subdivision shall be submitted on the
“Primary Treating Physician's Progress Report” form (Form PR-
2) contained in Section 9785.2, or in the form of a narrative report
Opportunity to Dispute communicated to Claims Administrator on 10/22/2015. A response from Claims Administrator was not
received for this review.
Based on the aforementioned documentation and guidelines, reimbursement for Evaluation and Management 99215 & WC002
is warranted.
99215 and WC002 The Claims Administrator denied
services as unauthorized.
Provider seeking remuneration for 99215 Established Patient Evaluation and Management, and WC002 Primary Treating
Physician Report submitted for date of service 06/26/2015.
The Claims Administrator denied services as unauthorized.
Communication from Legal Parties, dated June 10, 2013, indicates Provider was appointed the Primary Treating
Physician.
Primary Treating Physicians do not require authorization to treat Injured Workers for follow-up care on accepted body parts.
Opportunity to Dispute Edibility communicated to Claims Administrator on 10/09/2015; response not yet received.
Abstracted information relating to evaluation and management services indicated the following:
History: Comprehensive
HPI: Problem Focused
ROS: Problem Focused
O “Reviewed, complete” no systems documented.
 Other: Problem Focused
o “Reviewed, no changes required” previous documentation not refereed to or submitted for comparison.
Exam: Exp. Problem Focused
Exp. Problem Focused
Medical Decision Making: Moderate
Multiple: Presenting Problems/Diagnosis
Limited Complexity of data:

119. Risk: High -see medications
Problem Focused/Expanded PF/ Moderate= 2 of 3/Meet or Exceed = 99213
Unless otherwise stated in a Contractual Agreement, WC002 Primary Treating Physician Progress Reports are
Reimbursable when an Injured Worker is seen by the Primary Treating Physician for continuing medical care.
PR-2 report indicates 06/26/2015 exam resulted in referral for FRP Evaluation and a written prescription for medications.
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for 99213 & WC002 and is
not indicated for 99215.
The table below describes the pertinent claim line information.
99215 and WC002 The Claims Administrator denied
services as “unauthorized.”
Communication dated August 23, 2013 signed by the Claims Administrator, addressed to the Provider,
verifies Primary Physician Designation pursuant to LC §4600.
Contractual Agreement Not submitted for IBR.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 1/27/2016; response not yet received.
The determination of an Evaluation and Management service for Established Patients require two of three key components in
the following areas:
1)History : Chief Complaint, History of Present Illness, Review of Systems (Inventory of Body Systems), Past Family and Social
History.
2)Examination: Problem Focused, Expanded Problem Focused, Detailed Comprehensive “(General multi-system examination, or
complete examination of a single organ system or other symptomatic related body area(s) or organ
system(s).”
3)Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a
management option, which is determined by considering the following factors:
a)The number of possible diagnoses and/or the number of management options that must be considered;
b)The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed,
and analyzed; and
c)The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s
presenting problem(s), the diagnostic procedure(s), and/or the possible management options.
Abstracted information date of service 07/20/2015 resulted in the following Established Evaluation and Management service:

120. 99215.
Documentation indicates Provider is the Primary Treating Physician and Injured Worker was seen for on-going medical
treatment. DWC states, “The purpose of the 45-day rule in California Code of Regulations, Title 8, section 9785(f)(8) is to make
sure that in the case of continuing treatment, that the patient’s progress is monitored no less than once every 45 days.” However,
“Within a 45-day period, the primary treating physician can bill for as many
PR-2’s as are medically necessary.”
Unless otherwise dictated by Contractual Obligation, PR-2 reports are reimbursable when an Injured Worker is treated for
continued medical care.
Progress Repot 07/20/2015 reflects the visit was medically necessary; RFA for aquatic therapy, MRI right hand, physical
therapy and medication.
Based on the aforementioned guidelines, reimbursement is recommended for documented service 99215 and California Specific
Reporting Code WC002
99215 and WC002 The Claims Administrator’s denied
reimbursement due to unauthorized
services
Provider seeking remuneration for 99215 Evaluation and Management and WC002 Primary Treating Physician Report submitted
for date of service 06/22/2015.
. The Provider is the Primary Treating Physician. Status verified by 09/09/2013 letter to Provider from Claims Administrator.
As the designated Primary Treating Physician, authorization for follow-up visits are not required.
Documentation submitted supports Evaluation and Management service performed on 06/22/2015.
Unless stipulated by A Contractual Agreement, WC002 California Specific Report is reimbursable when on-going treatment of
an accepted injury is rendered. The PR-2 report reflects treatment for established injury.
Contractual Agreement not submitted for IBR.
Opportunity to Dispute communicated to Claims Administrator on 11/19/2015. A response from Claims Administrator was not
received for this review.
Based on the aforementioned documentation, reimbursement for Evaluation and Management 99215 & WC002 is warranted.

121. 99215, WC002, and
J3490 x 2
Claims Administrator denied codes
with rationale not authorized.
Provider seeking remuneration for billed codes 99215, WC002, and J3490 x 2 (NDC 53746046600) on date of service
05/05/2015
Claims Administrator denied codes with rationale not authorized.
Communication from Claims Administrator to Provider dated May 25, 2015 shows “Recommend prospective request for 1
prescription of Motrin 800mg, #120 dispensed between 5/5/2015 and 5/5/2015 be certified”
Reimbursement of NDC 53746046600 is warranted.
Communication dated November 21, 2013 from Legal Party to Claims Administrator shows Provider as the Primary Treating
Physician.
E/M visits do not require prior authorization from the Primary Treating Physician. Therefore, reimbursement of 99215 is
warranted.
Provider submitted a Primary Treating Physician’s Progress Report which is required of the Provider. PR-2 documents services
performed on 9/05/2015.
Reimbursement of WC002 is warranted.
Based on information reviewed, reimbursement of codes 99215, WC002, and J3490 x 2 is recommended.
Claims Administrator submitted communication to Maximus after the Provider had filed this dispute. Claims Administrator’s
EOR submitted shows a payment in the amount of $205.51 was processed on 11/18/2015.
If Provider has been reimbursed the amount of $205.51, then Claims Administrator is only responsible for the IBR fee of $195.00
to be paid to Provider
99215-25 Claims Administrator denied code Provider is dissatisfied with denial of CPT 99215-25.

122. with rationale “The visit or service
billed, occurred within the global
surgical period and is not separately
reimbursable”
Claims Administrator denied code with rationale “The visit or service billed, occurred within the global surgical period and is
not separately reimbursable”
Provider appended modifier -25; significant and separate evaluation and management service by the same physician on the day
of a procedure.
Provider denies he performed any surgical procedure and warrants the E&M service for date of service 4/21/2015.
Documentation submitted states procedure performed on date of service 4/21/2015.
Opportunity for Claims Administrator to Dispute Eligibility letter was sent on 9/22/2015.
A response from Claims Administrator was not received for this review.
Based on documentation reviewed, reimbursement of 99215 is warranted.
99215-25, 62370, and
76942-26
Claims Administrator denied
services indicating on the
Explanation of Review “No
separate payment was made because
the value of the service is included
within the value of another service
performed on the same day”
CMS-1500 reflects place of service, “24.”
Authorization submitted for review reflects “Approved” by Claims Administrator on 10/07/14 pump refills and maintenance,
supplies, and pump reprograms. Also meeting “medical necessity” are categories: Miscellaneous, DME and Office Visit between
10/1/2014–12/31/2014.
Provider submitted documentation including a Follow-Up Report, Intrathecal Pump Maintenance and Administration Record,
and Session Data Report.
Provider billed code 99215-25 for an Established Patient Office visit, Significant, separately identifiable Evaluation and
Management.
Reimbursement of 99215-25 is warranted.
Documentation submitted is supported for billed codes 62370 and 76942. therefore, reimbursement is warranted for both codes.
Opportunity to Dispute sent to Claims Administrator on 1/21/2016 ; response not yet received, OMFS will be utilized to
determine payment.

123. 99215-25, WC002,
G0434, 96101, and
99358 x 2
Claims Administrator’s denial
rationale “Services not provided or
authorized by designated (Network)
Providers”
Provider is dissatisfied with denial of codes 99215-25, WC002, G0434, 96101, and 99358 x 2
Claims Administrator’s denial rationale “Services not provided or authorized by designated (Network) Providers”
Provider billed codes 99215-25, WC002, G0434, 96101, and 99358 x 2 on a CMS 1500.
Per coding guidelines, CPT 99358, Prolonged evaluation and management service before and/or after direct patient care; first
hour, is only billed once per date of service.
PR-2 submitted documents “Review of Medical Record: 30 minutes” along with services of 99215, G0434 and 96101.
Document dated 07/30/2015 and signed by Claims Administrator states “Specific Request: RETRO: pain/Disability Evaluation
with Oswestry Exam on DOS 6-17-15, OV –99215,UDS-G0434, Oswestry Exam –96101, 99358 x 2 units. Approved per Nurse”
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Authorization dated 07/30/2015 is contract in nature and therefore, reimbursement is warranted for 99215-25, WC002, G0434,
96101 and 99358.
Provider’s SBR states a 10% PPO discount is to be applied to OMFS

124. 99354 The Claims Administrator denied
services based on documentation.
CPT 99354 Definition: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the
usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service).
CMS 1500 indicates a series of services performed include ding a New Patient Evaluation.
EOR indicates reimbursement for 99213 , Office Evaluation.
CPT 99213 is a Parent Code to add-on CPT 99354.
CPT 99213 : Office or other outpatient visit for the evaluation and management of an established patient, typically, 15 minutes
are spent face-to-face with the patient and/or family.
Primary Treating Physician’s Progress Report, Page 1, Provider indicates “Time spent with patient 52 minutes”.
Pursuant MLN Matters Number MM5972: You can only bill the prolonged services codes if the total duration of all physician
or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and
management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30
minutes).
CMS Manual System, Pub 100-04 Medicare Claims Processing : Threshold Time to Bill Code 99354 billed with
Office/Outpatient and Consultation Code 99213 is 45 minutes.
Opportunity for Claims Administrator to Dispute sent on 3/23/2016. A response from Claims Administrator was not received for
this review
.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 99354.
99354 and
99355
Provider is dissatisfied with denial of codes 99354 and 99355.
Claims Administrator denied codes and indicated on the Explanation of Review “Documentation provided does not justify
payment for a Prolonged Evaluation and Management Service.”
Provider billed codes 99215, 99354 x 1 and 99355 x 2.
99215 -Typically, 40 minutes are spent face-to-face with the patient and/or family.
99354 -Prolonged service in the office or other outpatient setting requiring direct patient
contact beyond the usual service; first hour (List separately in addition to code for office
or other outpatient Evaluation and Management service).
99355-Prolonged service in the office or other outpatient setting requiring direct patient contact

125. beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service).
Per review of the report submitted, Provider documents on page 12 “Time spent with the patient today: 3 hours and 15 minutes.”
Based on information reviewed, reimbursement of codes 99354 and 99355 is warranted.
99354 and 99355 ISSUE IN DISPUTE :Provider seeking remuneration for 99354 & 99355 Prolonged Services with Direct Face-to-Face Contact
performed on 07/21/2015.
The Claims Administrator denied services based on documentation.
CCR §9789.12.13. Correct Coding Initiative.(a) The National Correct Coding Initiative Edits (“NCCI”) adopted by the CMS
shall apply to payment s for medical services under the Physician Fee Schedule. Except where payment ground rules differ from
the Medicare ground rules, claims administrators shall apply the NCCI physician coding edits and medically unlikely edits to
bills to determine appropriate payment. Claims Administrators shall utilize the National Correct Coding Initiative Coding Policy
Manual for Medicare Services. If a billing is reduced or denied reimbursement because of application of the NCCI, the claims
administrator must notify the physician or qualified non-physician practitioner of the basis for the denial, including the fact that
the determination was made in accordance with the NCCI.
Authorization to “treat, dated 07/08/2015, signed by The Claims Administrator addressed to the Provider indicates services are
authorized. Communication does not stipulate restrictions for services.
CPT 99354Definition: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the
usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service).
CPT 99355 Definition :Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the
usual service; each additional 30 minutes (list separately in addition to code for prolonged service)
CMS 1500 indicates a series of services performed includeding a New Patient Evaluation.
EOR indicates reimbursement for 99204, New Patient Evaluation.
CPT 99204 is a Parent Code to add-on CPT 99354.
CPT 99355 is an add-on code to 99354.
Consideration of time for add-on services begins when the time involved with the Parent Code ends.
CPT 99204 Definition: Office or other outpatient visit for the evaluation and management of a new patient, which requires these
3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided

126. consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually , the presenting problem(s) are of
moderate to high severity. Typically , 45 minutes are spent face-to-face with the patient and/or family.
Primary Treating Physician’s “First Report of Injury , Page 2, the Prouderindicates “ 2 hours and 3 (three) minutes” of face-to-
face time with the Injured Worker.
99204 @ 45 minutes + 99354 @ 60 min = 1.5 hours + 99354 @ .50 min = 2 hours.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 99354 and 99355.
99354 and 99355 The Claims Administrator denied
99354 and 99355 due to insufficient
information to adjudicate claim.
Provider seeking remuneration for 99354, 99355 for date of service 01/06/2016.
The Claims Administrator denied 99354 and 99355 due to insufficient information to adjudicate claim.
AMA CPT 2015 Code Description:
99354: Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary
procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (list
separately in addition to code for office or other outpatient evaluation and management or psychotherapy service)
Add-On Code 99355: Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the
primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each
additional 30 minutes (list separately in addition to code for prolonged service)
EOR reflects submitted Evaluation and Management Code 99204, parent code to 99354.
MLN Matters Document MM5972 -Prolonged Services with Direct Face-to-Face Patient Contact Service Documentation is
required in the medical record about the duration and content of the medically necessary evaluation and management service and
prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified
NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the
CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of
service. (Emphasis added).

127. Documentation for “Second Opinion Orthopedic Consultation,” does not indicate the start and end time of Evaluation and
Management service 99204. Without a start and end time for 99204, the use of 99354 and 99355 cannot be confirmed.
Based on the aforementioned documentation and guidelines, reimbursement is not indicated for 99354 and 99355
99354 and 99355 The Claims Administrator denied
services based on documentation.
99354 & 99355 Prolonged Services with Direct Face-to-Face Contact performed on 07/21/2015.
The Claims Administrator denied services based on documentation.
CCR §9789.12.13.Correct Coding Initiative.(a) The National Correct Coding Initiative Edits (“NCCI”) adopted by the CMS
shall apply to payments for medical services under the Physician Fee Schedule. Except where payment ground rules differ from
the Medicare ground rules, claims administrators shall apply the NCCI physician coding edits and medically unlikely edits to
bills to determine appropriate payment. Claims Administrators shall utilize the National Correct Coding Initiative Coding Policy
Manual for Medicare Services. If a billing is reduced or denied reimbursement because of application of the NCCI, the claims
administrator must notify the physician or qualified non-physician practitioner of the basis for the denial, including the fact that
the determination was made in accordance with the NCCI.
Authorization to “treat,” dated 07/08/2015, signed by The Claims Administrator addressed to the Provider indicates services are
authorized. Communication does not stipulate restrictions for services.
CPT 99354 Definition: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the
usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service).
CPT 99355 Definition: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the
usual service; each additional 30 minutes (list separately in addition to code for prolonged service)
CMS 1500 indicates a series of services performed including a New Patient Evaluation.
EOR indicates reimbursement for 99204, New Patient Evaluation.
CPT 99204 is a Parent Code to add-on CPT 99354.
CPT 99355 is an add-on code to 99354.
Consideration of time for add-on services begins when the time involved with the Parent Code ends.
CPT 99204 Definition: Office or other outpatient visit for the evaluation and management of a new patient, which requires these
3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity.
Counseling and/or coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically 45 minutes are spent face-to-face

128. with the patient and/or family.
Primary Treating Physician’s “ First Report of Injury , Page 2, the Prouder indicates “2 hours and 3 (three) minutes ” of
face -to-face time with the Injured Worker.
99204 @ 45 minutes + 99354 @ 60 min = 1.5 hours + 99354 @ .50 min = 2 hours.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 99354 and 99355
99354, 99355, 99358,
and 99359
Claims Administrator denied
service with the following rational:
99354 & 99355:
Report/documentation does not
indicate service was performed.
99358 & 99359 “No Separate
payment was made because the
value of the service is included
within the value of another service
performed on the same day.”
Provider seeking remuneration for Prolonged Services with Face-to-Face Contact, 99354 (parent code) and 99355 (add-on), and
Prolonged Services without Face-to-Face Contact 99358 (parent code) and 99359 (add-on), performed on 04/29/2015.
Claims Administrator denied service with the following rational:
99354 & 99355: Report/documentation does not indicate service was performed.
99358 & 99359 “No Separate payment was made because the value of the service is included within the value of another service
performed on the same day.”
MLN Matters Document MM597-Prolonged Services with Direct Face-to-Face Patient Contact Service Documentation is
required in the medical record about the duration and content of the medically necessary evaluation and management service and
prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified
NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the
CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of
service.
Psychology Report indicates total time spent on tasks. Actual start and end relating to 99354 and 99355 is not indicated. Without
a start and end time, the actual time spent on specific codes 99354 & 99355 cannot be determined. As such, reimbursement is
Upheld.
CPT 99358 and 99359 are considered part of the Evaluation and Management service when performed on the same day.
However, documentation of an authorization for non-face-to face services, specifically authorizing 99358 and 99359 was
submitted for IBR.
Authorization, signed “3/26/2015” by the Claims Administrator for a New Patient Office Visit and CPT Codes 99358 & 99359,
and Psychological Testing.
Signed Authorization includes the following information:
Record Review 99358 and 99359
“Record review by agreement of Claims Administrator is a separately reimbursable, unbundled service,” listed under “Procedure
Requested.”
Although 99358 and 99359 are considered part of an E&M service, the Authorization –reflecting these services, was signed and

129. acknowledged by the Claims Administrator as a requested service by the Provider thereby severing the bundled unit service into
separately reimbursable units by mutual agreement.
Evaluation and Management report documented the time relating to 99358 and 99359 Non-Face-to-Face services.
Signed attestation regarding the content of the E&M report, including CPT codes 99358 and 99359, can be found on the last
page of the report.
E&M Report indicates 1 unit for first hours of parent code 99358 and 1 unit “99359 each additional 7units.”
99354, 99355, and
99359
Claims Administrator denied
service with the following rational:
99354 & 99355: “Documentation
provided does not justify payment
for a Prolonged Evaluation and
Management service.”
99359 “No Separate payment was
made because the value of the
service is included within the value
of another service performed on the
same day.”
Claims Administrator denied service with the following rational:
99354 & 99355: “Documentation provided does not justify payment for a Prolonged Evaluation and Management service.”
99359 “No Separate payment was made because the value of the service is included within the value of another service
performed on the same day.”
MLN Matters Document MM597-Prolonged Services with Direct Face-to-Face Patient Contact Service Documentation is
required in the medical record about the duration and content of the medically necessary evaluation and management service and
prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified
NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the
CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of
service.
Psychology Report indicates total time spent on tasks. Actual start and end relating to 99354 and 99355 is not indicated. Without
a start and end time, the actual time spent on specific codes 99354 & 99355 cannot be determined. As such, reimbursement is
Upheld.
CPT 99359 is considered part of the Evaluation and Management service when performed on the same day.
However, documentation of an authorization for non-face-to face services, specifically authorizing 99359 was submitted for IBR.
Authorization, signed “3/24/2015” by the Claims Administrator for a New Patient Office Visit and CPT Codes 99358 & 99359,
and Psychological Testing.
Signed Authorization includes the following information:
Record Review 99358 and 99359
“Record review by agreement of Claims Administrator is a separately reimbursable, unbundled service,” listed under “Procedure
Requested.”
Although 99358 and 99359 are considered part of an E&M service, the Authorization –reflecting these services, was signed and
acknowledged by the Claims Administrator as a requested service by the Provider thereby severing the bundled unit service into

130. separately reimbursable units by mutual agreement.
Evaluation and Management report documented the time relating to 99358 and 99359 Non-Face-to-Face services.
99358 was reimbursed by Claims Administrator on the second EOR.
E&M Report indicates “11 99359 each additional 30 mins.”
EOR submitted reflects a 5% PPO discount to be applied to reimbursement
99358 Services Bundled The above physician has been chosen PTP for this injured worker. Pursuant to Labor Code 5307.11, provider and claims
administrator agree to a one time agreement for payment of the following service(s) forth eabove named patient: Service: Record
Review, Billing Code: 99358, Inches 1 inch, Total: $1456.36”
and is signed by authorized claims administrator
99358 and 99080 Claims Administrator denied codes
indicating on the Explanation of
Review “service has a relative value
of zero and therefore no payment is
due ”
Documentation submitted includes the Provider’s Pre-Authorization and Pre-Negotiated Fee Arrangement which states
“Pursuant to Labor Code Section 5307.11, provider and claims administrator agree to a one time agreement for payment of the
following service(s) for the above named patient: Record Review 99358 $36.34 per 15 minute increment; Written Report 99080
$37.50 per page up to 6 max. By signing below, the authorized agent of the claims administrator pre-authorizes the above-noted
services at the rates indicated”. Document is signed by the authorized agent of Claims Administrator and dated 08/31/15.
Pursuant to LC § 5307.11–“the medical fee schedule shall not apply to the contracted reimbursement rates.”
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11:
5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates. Except as provided in subdivision (b) of Section 5307.1,
the official medical fee schedule shall establish maximum reimbursement rates for all medical services for injuries subject to this
division provided by a health care provider or health care facility licensed pursuant to Section 1250 of the Health and Safety
Code other than those specified in contracts subject to this section.
Provider documents Record Review as 5.5 hours along with a 12 page report.
Based on the aforementioned guidelines, RFA dated 8/31/15 signifies the agreement of codes 99358 and 99080 between the
two parties. Therefore, reimbursement of codes 99358 and 99080 is warranted.
99358 and 99359 ANALYSIS AND FINDING

131. Based on review of the case file the following is noted:

ISSUE IN DISPUTE
:
Provider
seeking
remuneration for
99358
Prolon
ged
Evaluation and Management services before and/or after direct patient care; first
hour and
993
59
Prolonged Evaluation and Management services each additional 30
minutes, s
ubmitted for date of serviced
11/05/2015
.

Claims Administrator denied
99358 and
99359
with the following rational: “
N
o separate
payment
was made because the value of the service is included within the value of
another service performed on the same day
.”

Authorization, signed
07
/17
/2015
by the Claims Administrato
r
, includes
the
following services as
authorized
:

99205 Initial Evaluation

132. 
99358 and 99359
–
Record Review

96101 Psych Testing

§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of
the Health and Safety Code, and a contracting agent, employer, or carrier may contract
for reimbursement rates
different from those in the fee schedule adopted and revised
pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier contract
for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rat
es
.
IBR Final Determination OVERTURN, Practitioner
CB16-
0000
593
Page 3 of 3

Although 99358 and 99359
are considered part of an E&M service, the Authorization
reflecting these services
is
signed and acknowledged by the Claims Administrator as a
req
uested service by the Provider thereby severing the bundled unit services
into
separately reimbursable units by mutual agreement if the documentation supports the
billed services.

Document entitled “Psychiatric
Evaluation
Re
port
,” under “Summary
of
Ch

133. arges,”
documents
the time relating to 99358
and 99359
as follows:
“
Record Review & Other
Non Face to Face Activities: 4 Hours 30 Minutes
”

1
Prolonged non face to face service-rec. review first hour.
(99358)

7
each additional 30 mins (99359)

Authorization dated 07/17/2015 is contractual in nature; 99358
and 99359
time is clearly
documented.

Contract Agreement not submitted for review.

Based on the aforementioned documentation and guidelines, reimbursement is
warranted for 99358 and
99359
.
ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE IN DISPUTE
:
Provider
seeking
remuneration for
99358
Prolon
ged
Evaluation and Management services before and/or after direct patient care; first
hour and
993
59
Prolonged Evaluation and Management services each additional 30

134. minutes, s
ubmitted for date of serviced
11/05/2015
.

Claims Administrator denied
99358 and
99359
with the following rational: “
N
o separate
payment
was made because the value of the service is included within the value of
another service performed on the same day
.”

Authorization, signed
07
/17
/2015
by the Claims Administrato
r
, includes
the
following services as
authorized
:

99205 Initial Evaluation

99358 and 99359
–
Record Review

96101 Psych Testing

§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of
the Health and Safety Code, and a contracting agent, employer, or carrier may contract
for reimbursement rates
different from those in the fee schedule adopted and revised
pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier contract
for reimbursement rates different from those in the fee

135. schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rat
es
.
IBR Final Determination OVERTURN, Practitioner
CB16-
0000
593
Page 3 of 3

Although 99358 and 99359
are considered part of an E&M service, the Authorization
reflecting these services
is
signed and acknowledged by the Claims Administrator as a
req
uested service by the Provider thereby severing the bundled unit services
into
separately reimbursable units by mutual agreement if the documentation supports the
billed services.

Document entitled “Psychiatric
Evaluation
Re
port
,” under “Summary
of
Ch
arges,”
documents
the time relating to 99358
and 99359
as follows:
“
Record Review & Other
Non Face to Face Activities: 4 Hours 30 Minutes
”

1
Prolonged non face to face service-rec. review first hour.
(99358)

7

136. each additional 30 mins (99359)

Authorization dated 07/17/2015 is contractual in nature; 99358
and 99359
time is clearly
documented.

Contract Agreement not submitted for review.

Based on the aforementioned documentation and guidelines, reimbursement is
warranted for 99358 and
99359
.
99358 and 99359 Claims Administrator denied 99358
and 99359 with the following
rational: “According to the Fee
Schedule, this charge is not
covered.”
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
Provider seeking remuneration for 99358 Prolonged Evaluation and Management services before and/or after direct patient care;
first hour and 99359Prolonged Evaluation and Management services each additional 30 minutes, submitted for date of serviced
11/17/2015.
Claims Administrator denied 99358 and 99359 with the following rational: “According to the Fee Schedule, this charge is not
covered.”
Authorization, signed 10/5/2015 by the Claims Administrator, includes the following services as authorized:
99205 Initial Evaluation
99358 and 99359–Record Review
96101 Psych Testing
§ 5307.11 : A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
Schedule , the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Although 99358 and 99359 are considered part of an E&M service, the Authorization reflecting

137. these services is signed and acknowledged by the Claims Administrator as a requested service by the Provider thereby severing
the bundled unit services into separately reimbursable units by mutual agreement if the documentation supports the billed
services.
Document entitled “Psychiatric Evaluation Report,” under “Summary of Charges,” documents the time relating to 99358 and
99359 as follows: “Record Review & Other Non Face to Face Activities: 5 Hours 30 Minutes”
1Prolonged non face to face service-rec. review first hour. (99358)
9each additional 30 mins (99359)
Authorization dated 10/5/2015 is contractual in nature; 99358 and 99359 time is clearly documented.
Contractual Agreement submitted for review shows a 95% reimbursement rate for Workers’
Compensation claims.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 99358 and 99359.
99358 and 99359 Claims Administrator denied 99358
and 99359 with the following
rational: “According to the Fee
Schedule, this charge is not
covered.”
Provider seeking remuneration for 99358 Prolonged Evaluation and Management services before and/or after direct patient care;
first hour and 99359 Prolonged Evaluation and Management services each additional 30 minutes, submitted for date of serviced
11/17/2015.
Claims Administrator denied 99358 and 99359 with the following rational: “According to the Fee Schedule, this charge is not
covered.”
Authorization, signed 10/5/2015 by the Claims Administrator, includes the following services as authorized:
99205 Initial Evaluation
99358 and 99359–Record Review
96101 Psych Testing
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code shall not apply to the contracted reimbursement rates.
Although 99358 and 99359 are considered part of an E&M service, the Authorization reflecting these
Services is signed and acknowledged by the Claims Administrator as a requested service by the Provider thereby severing the

138. bundled unit services into separately reimbursable units by mutual agreement if the documentation supports the billed services.
Document entitled “Psychiatric Evaluation Report,” under “Summary of Charges,” documents the time relating to 99358 and
99359 as follows: “Record Review & Other No- Face to Face Activities: 5 Hours 30 Minutes”
1Prolonged non face to face service-rec. review first hour. (99358)
9each additional 30 mins (99359)
Authorization dated 10/5/2015 is contractual in nature; 99358 and 99359 time is clearly documented.
Contractual Agreement submitted for review shows a 95% reimbursement rate for Workers’ Compensation claims.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 99358 and 99359
99358 and 99359 Claims Administrator denied codes
indicating on the Explanation of
Review “According to the Official
Medical Fee Schedule, this service
has a relative value of zero”
Provider is dissatisfied with denial of codes 99358 and 99359
Claims Administrator denied codes indicating on the Explanation of Review “According to the Official Medical Fee Schedule,
this service has a relative value of zero”
Effective 1/1/2014 CPT codes 99358 and 99359 are bundled codes and payment is covered under other services.
Documentation submitted includes the Provider’s Request for Authorization which states: “Service/
Good Requested: Record Review; CPT/HCPCS Code: 99358/99359”...“Record review, by the agreement of the claims
administrator, is a separately reimbursable, unbundled service”. Claims Administrator signed and dated (12
/17/14) the RFA and checked the ‘Approved’ box.
Pursuant to LC § 5307.11 –“the medical fee schedule shall not apply to the contracted reimbursement rates.”
California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11:
5307.11. A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rates. Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish
maximum reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or
health care facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject
to this section.
Provider documents Face to Face time with patient 4 hours 25 minutes and Record Review & Other Non-Face to Face Activities
5 hours and 45minutes
Based on the aforementioned guidelines, RFA dated 12/17/14 signifies the agreement of codes 99358 and 99359 between the

139. two parties. Therefore, reimbursement of codes 99358 and 999359 is warranted.
EOR received reflects 5% PPO discount to be applied to reimbursement
99358 and 99359 The Claims Administrator denied
services indicating “charge not
covered per OMFS.”
Opportunity to Dispute
communicated to Claims
Administrator on 02/29/2016 ,
response not yet received.
Contractual Agreement not submitted for IBR.
RFA dated 07/27/2015 signed by the Claims Administrator indicates CPT 99358 & 99359 “approved” for “record review.” RFA
does not indicate the number of units authorized.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to
Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code,
and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the
medical fee schedule for
that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the
contracted reimbursement rates.
Document dated 07/27/2015 is contract in nature.
Psychiatric Evaluation Report provides the definition and pricing relating to 99358 and 99359 and indicates the total time spent
specifically relating to the review of medical records as 2 hours and 30 minutes .
Based on the aforementioned documentation and guidelines, reimbursement is indicated 99358 x 1 unit and 99359 x 3units.
EOR reflects a 5% PPO discount to be applied to reimbursement.
99358 and 99359 Provider seeking remuneration
99358 Prolonged Services W/O face
-to-face contact and add-on code
99359 each additional 30 minutes
(list separately).
The Claims Administrator denied
services indicating “This code is
either not valid or not available in
the California Fee Schedule.”
Opportunity to Dispute communicated to Claims Administrator on 03/01/2015, response not yet received.
Contractual Agreement not submitted for IBR.
Communication dated August 26, 2015 signed by the Claims Administrator indicates CPT 99358 & 99359 “authorized.”
Documentation does not indicate the number of units authorized.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to
Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code,
and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the

140. medical fee schedule for
that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the
contracted reimbursement rates.
Documentation dated August 26, 2015 is contract in nature.
Comprehensive urological consultation report documents “Reviewing the records 19.0 hours.”
Based on the aforementioned documentation and guidelines, reimbursement is indicated 99358 x 1 unit and 99359 x 9
99359 The Claims Administrator
reimbursed 1 of 11 units indicating
“scheduled allowance.”
Provider seeking full remuneration for 99359 Prolonged Services without face-to-face contact for date of service 12/23/2015.
The Claims Administrator reimbursed 1 of 11 units indicating “scheduled allowance.”
EOR’s indicate PPO deductions.
Contractual Agreement not received for IBR.
99359 Prolonged Service without face-to-face contact is a status indicator “B” code and is bundled, per
CCR § 9789.12.8, into the evaluation and management service performed on the same date of service.
Authorization for 99359, signed by the Claims Administrator on 11/20/2015, allows for 99359 but
does not indicate authorized units for 99359.
Page 1 of the report, the Provider indicates “a 1/2–inch stack” of medical records were reviewed.
No indication as to the type of records, i.e., paper, films, etc.
Page 8 of report indicates “6.5” hours of record review.
Summary of reviewed records not included in the report.
Without a clear authorization indicating the number of units allowed for Bundled Service 99359 non-face-to face time record
review, only 1 (one) allowable unit is indicated.
Based on the aforementioned documentation and guidelines additional reimbursement is not supported for CPT Code 99359
99359 The Claims Administrator
reimbursed 1 of 11 units indicating
“ scheduled allowance.”
Provider seeking full remuneration for 99359 Prolonged Services without face-to-face contact for date of service 12/23/2015.
The Claims Administrator reimbursed 1 of 11 units indicating “ scheduled allowance.”
EOR’s indicate PPO deductions.
Contractual Agreement not received for IBR.
99359 Prolonged Service without face-to-face contact is a status indicator “B” code and is bundled, per
CCR § 9789.12.8, into the evaluation and management service performed on the same date of service.
Authorization for 99359, signed by the Claims Administrator on 11/20/2015, allows for 99359 but
does not indicate authorized units for 99359.
Page 1 of the report, the Provider indicates“ a 1/2–inch stack” of medical records were reviewed.
No indication as to the type of records, i.e., paper, films, etc.

141. Page 8 of report indicates “6.5” hours of record review.
Summary of reviewed records not included in the report.
Without a clear authorization indicating the number of units allowed for Bundled Service 99359 non-
face-to face time record review, only 1 (one) allowable unit is indicated.
Based on the aforementioned documentation and guidelines additional reimbursement is not supported for CPT Code 99359
99499
-
86
ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE IN DISPUTE: Provider seeking
additional
remuneration for
Functional
Restoration
Evaluation
services, billed as Unlisted Procedure Code
99499
-
86
, for date
of service
0
3/11/2016.

The Claims Administrator’s reimbursement rational indicates the
d
ocumentation regarding
service and time required f
or
adjudication
consideration.

Authorization
dated 03/10/2016,

142. signed by the
Claims Administrator indicates the
following:
“
Please accept
this letter
as
authorization for (Injured Worker) to receive
Functional Restoration Program (One time, Full Day) a
t (Provider
) on
3/11/2016
”

9
9499
is a By Report code; a schedule allowance does not exist
and there is no assigned
value
.

Modifier
-
86: OMFS “This Modifier is used when prior authorization was received for
services that exceed OMFS ground rules.”

Functional Restoratio
n Program service authorized as per aforementioned
0
3/10/2016
a
uthorization
, meeting the criteria for Modifier
-
86
.

CMS 1500 reflects Modifier
-
86
appended
to CPT
99499.


143. OMFS allows for Unlisted Procedure Codes to be reimbursed by “By
Report.”

§9789.12.4 (c) “In determining the value of a By Report procedure
, consideration may be
given to the value assigned to a
comparable
procedure or analogous code. The comparable
IBR Final Determination
OVERTURN,
P
ractitioner
CB16
-
0000
8
8
6
Page
3
of
4
procedure or analogous code should reflect similar amount of resources, such as practice
expense, time, complexity, expertise, etc. as required for the procedure performed.”

There is no allowance listed under t
he OMFS for
the billed procedure code
99499
or,
more specifically,
Functional Restoration
Program
, and a comparable
procedure code does
not exist.

CPT
99499
By
Repo
rt Code is not subject to MPPR as there is no unit value or conversion
factor assoc
iated w

144. ith this By Report Code.

Opportunity to dispute Eligibility communicated with the Claims Administrator on
05/17/
2016; response received 06/07/2016
with recent EORs
indicating “additional
payment.” However, the dates of
services on
the recent
EOR do not reflect all of the dates of
service for this dispute; this review will not reflect this additional payment as reconciliation
between
recent
reimbursed
amount and the dates of services for this dispute cannot be
adequately
reconciled.

California State Assembly Bill 1177 amended the Labor Code effective January 1, 2002
to add §5307.11
: 5307.11. A health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier
may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Co
de, and a contracting agent, employer,
or carrier contract for reimbursement rates different from those in the fee schedule, the
medical fee schedule for that health care provider or health facility licensed pursuant to
Section 1250 of the Health and Safet
y Code
shall not apply to the contracted
reimbursement rates.
Except as provided in subdivision (b) of Section 5307.1, the official
medical fee schedule shall establish maximum reimbursement rates for all medical services
for injuries subject to this divis
ion provided by a health care provider or health care facility
licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in
contracts subject to this section.

Cli
nical Documentation
c

145. onfirms
a comprehensive
and
multi
-
specialty
serv
ice
provided by
three separate Providers in three sepa
rate specialties on 03/11/2016 as part of the
authorized
FRP service.

Contractual Agreemen
t provided for IBR, under the heading, Section Two
–
General
Provisions, item 4, reflects “90%” of eligible billed charges for procedure codes of no
assigned value.

B
ased on the aforementioned documentation and guidelines,
reimbursement is
indicated for Unlisted Procedure Code
99499
-
86.
99499 Claims Administrator denied
reimbursement with the following
rationales: “If a flat rate has been
Provider seeking remuneration for Functional Restoration Evaluation services, billed as Unlisted Evaluation and Management
Procedure Code 99499-86, for date of service 07/21/2015–07/23/2015.
Claims Administrator denied reimbursement with the following rationales: “If a flat rate has been agreed upon for the

146. agreed upon for the Functional
Restoration Program, please provide
a signed adjuster agreement”
Functional Restoration Program, please provide a signed adjuster agreement”
Payment for FRP is in dispute.
Modifier -86:OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Provider’s RFA reflects request for 16 days of FRP at Provider’s Usual and Customary Fee of $1120.00/day.
Letter dated June 30, 2015 from Utilization Review with Modified determination & Authorization states: “Units/Days
Requested: 16, Units/Days Authorized: 10; Begin Date 06/22/2015 Expiration Date: 08/10/2015,”
Meeting the criteria for Modifier -86. Provider’s fee of $1120/day, or a fee adjustment, was not reflected on
Authorization letter.
Documentation Entitled “Progress Report for Week 1” reflects dates of service 07/21/2015 –07/23/2015.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 99499 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Contractual Agreement not available for IBR; signed Authorization by Claims Administrator does not indicate a “By Report” or
PPO Reduction. As such, in absence of the actual contractual agreement, the signed authorization and the OMFS dictates
reimbursement.
Pursuant to LC § 5307.11:A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety
Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule
adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250
of the Health and Safety Code, and a contracting agent, employer,
or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care
provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rates.
The aforementioned June 30, 2015 Authorization is contractual in nature. As such, Provider’s Usual and Customary rates shall
apply
99499
Functional
Restoration
Evaluation
Claims Administrator denied
reimbursement with the following
rational: “The Unlisted or BR
service was not received or
Provider seeking remuneration for Functional Restoration Evaluation services, billed as Unlisted Evaluation and Management
Procedure Code 99499 for date of service 07/09/2015.
Claims Administrator denied reimbursement with the following rational: “The Unlisted or BR service was not received or
sufficiently identified or documented...”

147. sufficiently identified or
documented...”
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Authorization signed by Claims Administrator on 05/14/2015
CMS1500 reflects Modifier –86 appended to Unlisted Procedure Code, meeting the OMFS Ground Rules.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 99499 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement. Authorization signed by Claims Administrator on
5/14/2015 is contract in nature.
Based on guidelines and documentation reviewed, reimbursement for 99499 is warranted.
EOR dated 9/4/2015 shows reimbursement in the amount $1120.00. As Provider has been reimbursed in full, Claims
Administrator is responsible for the IBR application fee of $195.00
99499 The Claims Administrator based
$0.00 reimbursement on “negotiated
rate”.
Provider seeking remuneration for Functional Restoration Program services, billed as Unlisted Procedure Code
99499-86 for date of service 06/15/2015–06/18/2015.
The Claims Administrator based $0.00 reimbursement on “negotiated rate”.
CMS 1500 indicates Modifier -86.
Modifier -86: OMFS Modifier is used when prior authorization was received for services that
exceed OMFS ground rules.
CMS 1500, box 23, does not indicate a Prior/Retro Authorization Number.
Undated Correspondence to Claims Administrator indicates Provider ’s Usual and Customary fee of “$1120/day.”
The Authorization received for this review indicates “Specific request: additional functional restoration program Monday-
Thursday 8-4:30pm x final 20 days/authorized per Physician Advisor” dated 6/10/2015 and signed by
Claims Administrator.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”

148. There is no allowance or comparable code listed under the OMFS for service billed with procedure code
99499 or, more specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive
program. As such, a contractual agreement or the OMFS will dictate the level of reimbursement.
CCR § 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for
reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health
facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
Full Contractual Agreement not available for IBR; in absence of the actual contractual agreement, the signed authorization
directs reimbursement. The 06/10/2015 signed Authorization is contractual in nature.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 99499-86, pursuant to CCR §
5307.11.
99499-86 Provider is disputing the reimbursement for functional restoration services billed as CPT 99499 date of service 03/31/2014-
04/04/2014.
The Official Medical Fee Schedule and CPT 2014 Edition were reviewed.
CPT code 99499 has a Physician Fee Schedule status indicator “C.”.
If payable, status code “C” will be paid “By Report”, generally following review of documentation such as an operative or
progress report.
CCR 9789.12.4 “By Report” -Reimbursement for Unlisted Procedures / Procedures Lacking RBRVUs
(a) An unlisted procedure shall be billed using the appropriate unlisted procedure code from the CPT. The procedure shall be
billed by report (report not separately reimbursable), justifying that the service
was reasonable and necessary to cure or relieve from the effects of the industrial injury or illness. Pertinent information should
include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort and equipment
necessary to provide the service.
(b) (1) In accordance with section 9789.12.3, when procedures with status indicator codes C, N, or R, do not have RVUs
assigned under the CMS’ National Physician Fee Schedule Relative Value File, these services shall be billed by report, justifying
that the service was reasonable and necessary to cure or relieve from the effects of the industrial injury or illness. Pertinent
information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time,
effort and equipment necessary to provide the service.
Medical records, authorization requests and authorizations submitted and reviewed, indicated services functional restoration

149. services provided were authorized for dates of service 03/31/2014-04/04/2014. Provider documented Phase I of the two-six week
program is comprised of treatment provided 8:30am-4:00pm Monday thru Friday and cost is $1,121 per day. Medical record for
the treatment dates of 03/31/2014-04/04/2014 documented the worker’s progress which included: medical, psychological and
physical/functional; psychological coping progress and physical/functional progress charts. UR notice authorized: Week 1 & 2 of
functional restoration from 03/14/2014-05/13/2014.
Claims Administrator reimbursed the Provider $2681.55 prior to IBR submission, and an additional amount of $1,541.75 after
IBR case was received.
PPO contract was requested and not received; therefore recommended allowance was based on the documented Provider’s fee of
$5605.00.
Documentation satisfies the reporting requirements for an unlisted “By Report” code, fee was documented at time of service
authorization request, reimbursement warranted based on billed
amount $1,121 per day or $5,605.00 per week
99499-86 SBR by Claims Administrator
resulted in “duplicate claim” with
upheld recommended allowance of
“$0.00,”
Initial EOR indicated
“documentation” required for
reimbursement.
Provider seeking remuneration for Functional Restoration Evaluation services, billed as Unlisted Evaluation and
Management Procedure Code 99499-86, for date of service 05/26/2015, 05/27/2015 & 06/01/2015.
SBR by Claims Administrator resulted in “duplicate claim” with upheld recommended allowance of “$0.00,”
Initial EOR indicated “documentation” required for reimbursement.
Modifier -86: OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Contractual Agreement not available for IBR.
Authorization reviewed; “x 22 days” FRP “Approved by Physician Advisor, ” meeting the requirements for Modifier –86.
Usual and Customary Fee indicated on (undated /addressed ) correspondence as $1,120.00 per day;Claims ID & Injured Worker
noted on communication.
Opportunity to Dispute communicated to Claims Administrator on 08/18/2015; response not yet received.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.” §9789.12.4 (c) “In determining the value of a By
Report procedure, consideration may be given to the value assigned to a comparable procedure or analogous code. The
comparable procedure or analogous code should reflect similar amount of resources, such as practice expense, time, complexity,
expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 99499 or, more

150. specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Contractual Agreement not available for IBR; signed Authorization by Claims Administrator does not indicate a “By Report” or
PPO Reduction. As such, in absence of the actual contractual agreement, the signed authorization and the OMFS dictate
reimbursement.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for 99499 –86.
99499-86 Claims Administrator postponed
payment post documentation
review.
Provider seeking remuneration for Functional Restoration Evaluation services, billed as Unlisted Evaluation and
Management Procedure Code 99499-86, for date of service 05/04/2015 –05/07/2015 “Week Two” of FRP.
Claims Administrator postponed payment post documentation review.
Modifier -86:OMFS Modifier is used when prior authorization was received for services that exceed OMFS ground rules.
Contractual Agreement not available for IBR.
Authorization reviewed; requirement met for Modifier –86.
OMFS allows for Unlisted Procedure Codes to be reimbursed by “By Report.”
§9789.12.4 (c) “In determining the value of a By Report procedure, consideration may be given to the value assigned to a
comparable procedure or analogous code. The comparable procedure or analogous code should reflect similar amount of
resources, such as practice expense, time, complexity, expertise, etc. as required for the procedure performed.”
There is no allowance or comparable code listed under the OMFS for service billed with procedure code 99499 or, more
specifically, a Functional Restoration Program; a CPT Code has yet to be formulated for this comprehensive program. As such, a
contractual agreement or the OMFS will dictate the level of reimbursement.
Contractual Agreement not available for IBR; signed Authorization by Claims Administrator does not indicate a “By Report” or
PPO Reduction. As such, in absence of the actual contractual agreement, the signed authorization and the OMFS dictates
reimbursement.
09/02/2015 communication from Claims Administrator indicates 100% reimbursement of billed charges processed on
“08/13/2015,” post IBR filing date of 08/05/2015. IBR Filing Fee due Provide

151. Billing rules:
Arthroscopic
synovectomy of the
knee
Per CMS NCCI Edits: Arthroscopic synovectomy of the knee may be reported with CPT codes 29875 (limited synovectomy,
“separate procedure”) or 29876 (major synovectomy of two or three compartments). A synovectomy to “clean up” a joint on
which another more extensive procedure is performed is not separately reportable. CPT code 29876 may be reported for a
medically reasonable and necessary synovectomy with another arthroscopic knee procedure on the ipsilateral knee if the
synovectomy is performed in two compartments on which another arthroscopic procedure is not performed. For example, CPT
code 29876 should never be reported for a major synovectomy with CPT
code 29880 (knee arthroscopy, medial AND lateral meniscectomy) on the ipsilateral knee since knee arthroscopic procedures
other than synovectomy are performed in two of the three knee compartments.
DRG 455 ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE IN DISPUTE
:
Provider seeking remuneration
of DRG 455
performed on dates of
service
02/25/2016
–
02/29/2016

Cl
aims Administrator reimbursement rationale:
“
This charge was adjusted to comply with
the rate and rules of the contrac
t indicated
.

152. ”

PPO contract received states
“
less
o
r of
”
PCS rate or OMFS.

§ 9792.5.7
Requesting Independent Bill
Review
:

(a) If the provider further contests the amount of payment made by the claims
administrator on a bill for medical treatment services or goods rendered on or after
January 1, 2013, submitted pursuant to Labor Code sections 4603.2 or 4603.4, or bill
for medical
-
legal expenses incurred on or after January 1, 2013, submitted pursuant to
Labor Code section 4622, following the second review conducted under section
9792.5.5, the provider shall request an independent bill review. Unless consolidated
under
section 9792.5.12, a request for independent bill review shall only resolve:

(1) For a bill for medical treatment services or goods, a dispute over the
amount of
payment
for services or goods billed by a single provider involving one injured
employee, one
claims administrator, and either one date of service and one billing
code or one hospital stay, under the applicable fee schedule adopted by the
Administrative Director or, if applicable,
under a contract for reimbursement rates
under Labor Code section 5
307.11 covering one range of effective dates
.
IBR Final Determination OVERT URN
CB16-0000879
Page 3 of 3

Based on aforementioned guidelines and contractual agreement, additional reimbursement of
DRG 455

153. is warranted.

Claims Administrator
’
s communication received,
after this dispute was filed,
states
additional reimbursement in the amount of $55,465.51 plus IBR application fee of $195.00 is
being made to the Provider. If Provider has received payment in full, no further
reimbursement is ow
DRG 460 ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE IN DISPUTE
:
Provider is seeking remuneration of DRG 460 performed on dates
of service
12/29/2015
–
12/31/2015

Claims Administrator reimbursed le
ss than the Inpatient Fee Sche
d
u
le
with rationale
“
the
provider billed all lines at a rate that wa
s less than the inpatient fee schedule
.
”

154. 
Claims Administrator is not disputing DRG
billed by the provider.

Contractual Agreement not submitted for review.

§9789.20
. General Information for Inpatient Hospital Fee Schedule
—
Discharge On or
After July 1, 2004.

(a) This Inpatient Hospital Fee Schedule section of the Official Medical Fee Schedule
covers charges made by a hospital for inpatient services provided by
the hospital.

§9789.22
. Payment of Inpatient Hospital Services
:

(a) Unless otherwise provided by applicable provisions of this fee schedule, the
maximum payment for inpatient medical services shall be determined by multiplying
1.20 by the product of the hosp
ital’s composite factor and the applicable DRG weight
and by making any adjustments required by this fee schedule. The fee determined
under this subdivision shall be a global fee, constituting the maximum reimbursement
to a hospital for inpatient medical s
ervices not exempted under this section

Inpatient Hospital Fee Schedule maximum payment amount (
DRG weight x 1.2 x
hospital specific composite factor
).
IBR Final Determination OVERTURN
CB16-0000773
Page 3 of 3

Inpatient hospital claim
reimbursed
per DRG
weight x 1.2 x CF:

3.9998 x 1.2 x 11460.28 = $55,006.59


155. Based on guidelines and regulations, additional reimbursement is warranted for DRG
4
60.
DRG 468 ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE IN DISPUTE
:
Provider seeking remuneration of DRG 468 for inpatient dates of
service
12/03/2015
–
1
2/05/2015

C
laims
Administrator
’
s denial rationale
“
Please send a better copy of UB form
”


156. DRG 468:
REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC

Utilization Review Determination
letter
dated 10/12/2015 documents
“
Medical treatment
service approved
, if any
”
:
1.
Total knee arthrotomy with manipulation
under anesthesia
2.
Lysis of adhesions
3.
P
ossible
liner exchange
4.
S
urgical
assistant
5.
I
npatient
(x3 days)
6.
P
re
op medical clearance
7.
P
re
op labs: CBC, BMP, PT
8.
EKG
9.
P
ost
op
CPM machine rental (x14 Days)
*Under Utilization Review Decision(s) and Rationale:

157. “
Request: (L) Total knee
arthrotomy with manipulation under anesthesia has b
een approved
,
”
other services
requested above show
“
approved
”
as well.
IBR Final Determination OVERTURN, Inpatient
CB16-
0000
710
Page 3 of 3

Provider
’
s documentation submitted details inpatient services for Anklyosis, left knee,
post total
knee arthroplasty

Contractual Agreement submitted for review states
“
Facility agrees to
accept the lesser
of
the Anthem Rate as set forth in the PCS or one hundred percent (100%) of the
California division of Workers
’
Compensation Official Medical Fee Schedule
(
“
OMFS
”
).
”
PCS Rate sheet shows:
o
“
Knee/hip replacement: $30,000; Revenue codes: 0274 or
0278

158. ”

UB
-04 submitted lists REV code
0278

§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of
the Health and Safety Code, and a contracting agent, employer, or carrier may contract
for reimbursement rates different from those in the fee schedule adopted and revised
pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent,
employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rates.

Based
on aforementioned documentation, contractual agreement
and guidelines,
reimbursement of DRG 468 is warranted.
DRG 470 ANALYSIS AND FINDING
Based on review of the case file the following is noted:

ISSUE IN DISPUTE
:
Provider seeking remuneration of DRG 470 performed on dates of
service 10/27/2015
–
10/29/2015


159. Claims Administrator reimbursed $2
,
400.00 based on
“
the rate and rules of the contract
indicated.
”
Claims Administrator states
“
The
per diem rate is
much lesser than the DRG 470
FS on this case therefore the per diem rate was applied.
”

A copy of the PPO contractual agreement was submitted for review. Fourth Amendment to
the Agreement Between
and
effective September 1, 2008 Attachment A-2
states:
“
Reimbursement for both Inpatient and
Outpatient service, including all exclusions and stop loss calculations, provided to
Workers
’
Compensation
patients shall not exceed 100% of the state mandated fee schedule in force at
the
time of treatment.
”

§ 9792.5.4
Second Review and Independent Bill Review:

(a) “
Amount of payment
” means the amount of money paid by the claims
administrator for either:

(1) Medical treatment services or goods rendered by a provider or goods supplied in
accordance with Labor Code section 4600 that were authorized by Labor Code
section 4610, and for which there exists an applicable fee schedule adopted by the
Administrative Director for those categories of goods and services, including but not
IBR Final Determination OVERTURN

160. CB16-0000877
Page 3 of 4
limited to those found at sections 9789.10 to 9789.111,
or for which a contract for
reimbursement rates exists under Labor Code section 5307.11
.

§ 9792.5.7
Requesting Independent Bill Review:

(a) If the provider further contests the amount of payment made by the claims
administrator on a bill for medical treatment services or goods rendered on or after
January 1, 2013, submitted pursuant to Labor Code sections 4603.2 or 4603.4, or bill
for medical-legal expenses incurred on or after January 1, 2013, submitted pursuant to
Labor Code section 4622, following the second review conducted under section
9792.5.5, the provider shall request an independent bill review. Unless consolidated
under section 9792.5.12, a request for independent bill review shall only resolve:

(1) For a bill for medical treatment services or goods, a dispute over the
amount of
payment
for services or goods billed by a single provider involving one injured
employee, one claims administrator, and either one date of service and one billing
code or one hospital stay, under the applicable fee schedule adopted by the
Administrative Director or, if applicable,
under a contract for reimbursement rates
under Labor Code section 5307.11 covering one range of effective dates.

PPO
contract
’
s Workers
’
Compensation language is specific to:
“
Workers’
Compensation
patients shall not exceed 100% of the state mandated fee schedule in
force at the time of treatment.
”
Claims Administrator’s reimbursement rate
was based on
Per Day amount $1200.00
for Inpatient Services Rates

161. which was incorrect per PPO
contract.

Based on aforementioned guidelines
and contractual agreement, additional reimbursement of
DRG 470 is warranted.
DRG 472 The Claims Administrator indicates
Provider “paid correctly per fee
schedule and (Claims administrator)
PPO contract. Additionally, the
Claims Administrator asserts the
Provider has yet to contact (Claims
Administrator) regarding
contractual payment allowance.
Provider seeking additional remuneration for DRG 472 Spinal Fusion, submitted for date of service 11/11/2015.
Opportunity to Dispute Eligibility communicated with the Claims Administrator on 05/03/2015; response received 05/17/2016.
The Claims Administrator indicates Provider “paid correctly per fee schedule and (Claims administrator) PPO contract.
Additionally, the Claims Administrator asserts the Provider has yet to contact (Claims Administrator) regarding contractual
payment allowance.
Provider indicates “Network allowable” paid “appears to be a per diem rate for a different service,”
and “Network will not accept any submission of documents from any party other than the payor.”
Full Contractual Agreement Not Received for IBR.
Administrative Rules Article 5.5.0. § 9792.5.7.Requesting Independent Bill Review (b) Unless as permitted by section
9792.5.12, independent bill review shall only be conducted if the only dispute between the provider and the claims administrator
is the amount of payment owed to the provider. Any other issue, including issues of contested liability or the applicability of a
contract for reimbursement rates
under Labor Code section 5307.11 shall be resolved before seeking independent bill review.(Emphasis
added)
Although partial contractual language was submitted for review, the Claims Administrator has indicated
(refer to 2ndbullet point) that reimbursement for DRG 472 is per Contractual Agreement, as such, the full Contractual Agreement
is necessary to support a IBR’s review of the contractual language in its entirety in order to confirm or contradict the Claims
Administrator’s assertions.

162. DRG 491 Claims Administrator
reimbursement rational: “No further
reimbursement was made as the
maximum allowance has been
reached for this admission. Labor
Code 5307.1”
ISSUE IN DISPUTE
: Provider seeking full remuneration for Inpatient Hospital Services DRG 491Back & Neck Proc. Exc.
spinal fusion W/O CC/MCC performed 09/08/2014 -09/09/2014.
Claims Administrator reimbursement rational: “No further reimbursement was made as the maximum allowance has been
reached for this admission. Labor Code 5307.1”
§9789.21 . (o) "Inpatient Hospital Fee Schedule maximum payment amount" is that amount determined by multiplying the DRG
weight x hospital composite factor x 1.20 and by making any adjustments required in Section 9789.22 (G)(2).
DRG 491 is not listed in Section 9789.22 (G)(2) for additional fees.
Contractual Agreement Not Available for IBR. As such, 100% OMFS will be utilized to calculate payment pursuant to
§9789.21
DRG 500 ANALYSIS AND FINDING
Based on review of the case f
ile the following is noted:

163. 
ISSUE IN DISPUTE
: Provider is requesting additio
nal reimbursement for inpatient
services billed under DRG 500.

Claims Administrator reimbur
sed the Provider $28,393.65, with the following explanation:
the DRG submitted is not correct for the workers’ compensation services billed. Allowance
recommended for more appropriate DRG.

The document submitted did not substantiate
the billed ICD-10 codes submitted on the
UB04.

Provider submitted two operative reports, and discharge summary.

The Major Complications or
Co-morbidities, and other IC
D-10 diagnoses could not be
validated on the submitted documents.

Without the pertinent documentation to valida
te all billed ICD-10 codes, IBR could not
validate the billed DRG code 500.

No additional reimbursement is recommended
E1339-LL Claims Administrator re-assigned
E1399-LL (lease) to E0730
NU(new it)indicating:
Provider seeking full remuneration E1399 –LL Durable Medical Equipment Unlisted Code dispensed to Injured Worker for use
at home; date of service 01/19/2016.
Claims Administrator re-assigned E1399-LL (lease) to E0730 NU(new unit)indicating:

164. 
“Based on review services rendered
to be best described by this code
"E0730."
“Based on review services rendered to be best described by this code "E0730."
"Payer will pay rental rates on this durable good up to the purchase price. Purchase price has been met."
E1399 Is an Unlisted Durable Medical Equipment Code. The code reflected in the documentation represents an H-wave muscle
stimulator unit and is not comparable to the E0730 nerve stimulator (Tens) assigned by the Claims Administrator.
Modifier, LL reflected on the CM S 1500 form indicates rental price applied to purchase.
§9789.60.Durable Medical Equipment, Prosthetics, Orthotics, Supplies. (a) For services, equipment, or goods provided after
January 1, 2004, the maximum reasonable reimbursement for durable medical equipment, supplies and materials, orthotics,
prosthetics, and miscellaneous supplies and services shall not exceed one hundred twenty (120) percent of the rate set forth in the
CMS' Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule, as established by Section 1834
of the Social Security Act (42 U.S.C. § 1395m) and applicable to California.
Title 8, §9789.19 For services rendered on or after 4/1/2014, use: the OMFS Durable Medical Equipment, Prosthetics,
Orthotics, Supplies (DMEPOS) Fee Schedule applicable to the date of service
H-wave unit has not yet been assigned a DMEPOS code, as such, the Provider may be reimbursed a percentage of the billed
Usual and Customary Charge under the OMFS or an existing Contractual Agreement.
Provider is the Manufacturer of the H-wave Unit E1399, there are no other distributors for this unit.
Provider’s Usual and Customary fee indicated on invoice is $3,300.00. Invoice reflects unit delivered to Injured Worker’s home.
Invoice Reflects $3,300.00 E1399 Unit delivered to Injured Worker’s Home Address.
Contractual Agreement reflects 75% Usual and Customary charge.
Modifier –LL dictates previous rental/lease payment to be applied to purchase.
Based on the documentation and guidelines additional reimbursement is warranted for E1399
-NU as the equipment is a purchase, not a lease (LL).
E1339-LL
Decision After Appeal
Provider submitted appeal of
original denial of E1399 for no
Provider is dissatisfied with denial of E1399-LL on date of service 03/11/2013.
Claims Administrator denied code indicating on the Explanation of Review “not authorized ”

165. Initial IBR Decision authorization to the Workers’
Compensation Appeals Board.
Provider submitted appeal of original denial of E1399 for no authorization to the Workers’ Compensation Appeals Board.
Hearing dated 4/6/2016 which documents both parties present for dispute. Workers’ Compensation Administrative Law Judge
documents “Based on the content of IBR Appeal from the Waveform Lab, it is hereby ordered a 2nd IBR on the sole issue of
reasonable value of the H-wave multi functional unit”
E1399 Is an Unlisted Durable Medical Equipment Code. The code reflected in the documentation represents an H-wave muscle
stimulator unit.
§9789.60. Effective for services rendered on or after January 1, 2013, the maximum reasonable fees for Durable Medical
Equipment, Prosthetics, Orthotics, Supplies shall not exceed 120% of the applicable California fees set forth in the Medicare
calendar year 2012 “Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule” revised for
January 2013
H-wave unit has not yet been assigned a DMEPOS code. As such, the Provider may be reimbursed a percentage of the billed
Usual and Customary Charge under the OMFS or an existing Contractual Agreement.
Provider’s Usual and Customary fee was received showing $3300.00 purchase charge along with billing code to be used E1399
for the H-wave unit
Contractual Agreement reflects 85% reimbursement of billed charges.
Based on the Worker ’s Compensation Appeals Board ruling, reimbursement is warrantedfor E1399.
E1339-LL Claims Administrator denied code
indicating on the Explanation of
Review “not authorized”
Provider is dissatisfied with denial of E1399-LL on date of service 8/12/2015.
Claims Administrator denied code indicating on the Explanation of Review “not authorized”
IMR dated 9/17/2015 states “Final Determination: Overturn” and “all of the disputed tems/services are medically necessary and
appropriate”
E1399 Is an Unlisted Durable Medical Equipment Code. The code reflected in the documentation represents an H-
wave muscle stimulator unit.
§9789.60. Durable Medical Equipment, Prosthetics, Orthotics, Supplies. (a) For services, equipment, or goods provided after
January 1, 2004, the maximum reasonable reimbursement for durable medical equipment, supplies and materials, orthotics,
prosthetics, and miscellaneous supplies and services shall not exceed one hundred twenty
(120) percent of the rate set forth in the CMS' Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee
Schedule, as established by Section 1834 of the Social Security Act (42 U.S.C. § 1395m) and applicable to California.
Title 8, §9789.19 For services rendered on or after 4/1/2014, use: the OMFS Durable Medical Equipment, Prosthetics, Orthotics,
Supplies (DMEPOS) Fee Schedule applicable to the date of service

166. H-wave unit has not yet been assigned a DMEPOS code. As such, the Provider may be reimbursed a percentage of the billed
Usual and Customary Charge under the OMFS or an existing Contractual Agreement.
Provider’s Usual and Customary fee was received showing $3300.00 purchase charge along with billing code to be used E1399
for the H-wave unit
Contractual Agreement reflects 75% of Usual and Customary charges.
Modifier –LL dictates previous rental/lease payment to be applied to purchase.
Based on the documentation submitted and guidelines, additional reimbursement is warranted for E1399
E1339-LL Claims Administrator denied code
indicating on the Explanation of
Review “not authorized
Authorization dated 01/14/2016 states “Service being appealed/approved: Requested: Home H- wave device
(purchase) for the right
elbow, Approved: Home H-wave device (purchase) for the right elbow. E1399, Start Date: 01/14/2016 End
Date: 03/14/2016; Determination: Approval; Authorization #: 1985988.01
E1399 Is an Unlisted Durable Medical Equipment Code. The code reflected in the documentation represents an H-wave muscle
stimulator unit
§9789.60. Durable Medical Equipment, Prosthetics, Orthotics, Supplies. (a) For services,
equipment, or goods provided after January 1, 2004, the maximum reasonable reimbursement for durable medical equipment,
supplies and materials, orthotics, prosthetics, and miscellaneous supplies and services shall not exceed one hundred twenty (120)
percent of the rate set forth in the CMS' Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee
Schedule, as established by Section
1834 of the Social Security Act (42 U.S.C. § 1395m) and applicable to California.
Title 8, §9789.19 For services rendered on or after 4/1/2014, use: the OMFS Durable Medical Equipment, Prosthetics, Orthotics,
Supplies (DMEPOS) Fee Schedule applicable to the date of service
H-wave unit has not yet been assigned a DMEPOS code. As such, the Provider may be
reimbursed a percentage of the billed Usual and Customary Charge under the OMFS or
an existing Contractual Agreement.
Provider’s Usual and Customary fee was received showing $3300.00 purchase charge
along with billing code to be used E1399 for the H-wave
E1399-LL The Claims Administrator’s denial
rational: “In order to review this
charge we will need a copy of the
invoice
E1399 –LL Durable Medical Equipment Unlisted Code dispensed to Injured Worker for use at home; date of service
08/03/20015.
The Claims Administrator’s denial rational: “In order to review this charge we will need a copy of the invoice”
Provider’s Usual and Customary fee indicated on CMS 1500 and Invoice to Injured Worker is $3,300.00.
Invoice Reflects $3,300.00 delivered to Injured Worker’s Home Address.
E1399 Is an Unlisted Durable Medical Equipment Code.
It is noted that the modifier, LL reflected on the CMS 1500 form indicates a “rental,” however, the Invoice delivered to Injured

167. Worker reflects entire purchase price of unit.
Invoice reflects unit delivered to Injured Workers Home Address.
Claims Administrator not denying E1399 was authorized.
§9789.60. Durable Medical Equipment, Prosthetics, Orthotics, Supplies. (a) For services, equipment, or goods provided after
January 1, 2004, the maximum reasonable reimbursement for durable medical equipment, supplies and materials, orthotics,
prosthetics, and miscellaneous supplies and services shall not exceed one hundred twenty (120) percent of the rate set forth in the
CMS' Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule, as established by Section 1834
of the Social Security Act (42 U.S.C. § 1395m) and applicable to California.
Title 8, §9789.19 For services rendered on or after 4/1/2014, use: the OMFS Durable Medical Equipment, Prosthetics, Orthotics,
Supplies (DMEPOS) Fee Schedule applicable to the date of service
H-wave stimulation is a form of electrical stimulation that differs from other forms of electrical stimulation, such as
transcutaneous electrical nerve stimulation (TENS), in terms of its waveform (MTUS–Chronic Pain Treatment Guidelines).
The main advantage of these technologies over currently applied electrical stimulators (eg, transcutaneous electrical nerve
stimulator [TENS], interferential [IF], neuromuscular electrical stimulation [NMES], high-volt galvanic, etc.) is that H-
Wave's(R) small fiber contraction does not trigger an activation of the motor nerves of the large white muscle fibers or the
sensory delta and C pain nerve fibers, thus eliminating the negative and painful effects of tetanizing fatigue, which reduces
transcapillary fluid shifts. Another function of the H-Wave(R) device is an anesthetic effect on pain conditions, unlike a TENS
unit which in the short term activates a hypersensory overload effect (gate theory) to stop pain signals from reaching the thalamic
region of the brain.(PubMed - 20048478)
A DMEPOS or HCPCS code has yet to be assigned for H-Wave devices and a there is no comparable service code. As such, the
Provider may be reimbursed a percentage of the billed Usual and Customary Charge under the OMFS or an existing Contractual
Agreement.
The Provider is the Manufacture of the Unit; Contractual Agreement reflects “15% off Usual and Customary.”
Based on the documentation and guidelines, reimbursement is warranted for E1399-LL
G0260 Provider remuneration for G0260 Status Indicator “T” injection procedure for sacroiliac joint; provision of anesthetic, steroid
and/or other therapeutic agent, with or without arthrography performed on
01/27/2016.
Claims Administrator denied reimbursement with rationale“ Per CA OP regs, non-surgical services
(ER, “ Facility -Only”, “Other” ) not paid in ASC setting .”
Amended Notice: Notice of Authorization dated December 22, 2015 from Utilization Review

168. Department “authorized : SI injections to low back under fluoroscopy and monitored anesthesia
to be done at Integrated Rehabilitation Medical Group”
CCR §5307.1(g)(2),the Administrative Director of the Division of Workers’ Compensation orders
that Title 8, California Code of Regulations, sections 9789.30 and 9789.31, pertaining to Hospital
Outpatient Departments and Ambulatory Surgical Centers Fee Schedule in the Offic
ial Medical Fee Schedule, is amended to conform to CMS’ hospital outpatient prospective payment system (OPPS). The
Administrative Director incorporates by reference, the Centers for Medicare and Medicaid Services' (CMS) Hospital Outpatient
Prospective Payment System (OPPS) certain addenda
published in the Federal Register notices announcing revisions in the Medicare payment rates. The
adopted payment system addenda by date of service are found in the Title 8, California Code of
Regulations, and Section 9789.39(b). Based on the adoption of the CMS hospital outpatient
prospective payment system (OPPS), CMS coding guidelines and the hospital outpatient prospective
payment system (OPPS) were referenced during the review of this Independent Bill Review (IBR) case.
Effective December 1, 2014, For services rendered on or after December 1, 2014, section
9789.31, subsections (a) and (b) are amended to incorporate by reference selected sections of the
updated calendar year 2014 version of CMS’ hospital outpatient prospective payment system
(HOPPS) published in the Federal Register on December 10, 2013, the updated fiscal year 2014
versions of CMS’ IPPS Tables 2, 4A, 4B, 4C, and 4J in the final rule of August 19, 2013 and
associated rules and notices to the IPPS final rule, respectively
G0260 code and 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image
guidance (fluoroscopy or ct) including arthrography when performed , are typically utilized for
billing SI Joint Injections performed with radiologic guidance.However, the surgical CPT code
27096 has an assigned indicator of “B”. The B indicator definition is “May be paid by fiscal
intermediaries/MACs when submitted on a different bill type” and is not paid under OPPS.
A review of the Addendum AA, ASC Covered Surgical Procedures for CY 2014does not list
HCPCS code 27096, but it does list G0260. Addendum B for CY 2014 does not list an APC Relative
weight for procedure code 27096 as this code is not reimbursable under OPPS. However, a
relative weight is listed for HCPCS G0260. Therefore, the Provider correctly submitted HCPCS
code G0260 for billing an OPPS anesthetic injection to sacroiliac joint with fluoroscopic guidance
and reimbursement is warranted for the ASC payment rate for HCPCS G0260.
CCR § 9789.30 (b) For services rendered on or after December 1, 2014, "APC Payment Rate"
means CMS' hospital outpatient prospective payment system rate for Calendar Year 2014.
HCPCS code G0260 has the assigned status indicator for this disputed code for 2014 is “T”. T =
Significant Procedure, Multiple Reduction Applies. Paid under OPPS and separate APC payment.
HCPCS code G0260 is grouped into APC 0207 Level III Nerve Injections.
CCR § 9789.33 For services rendered on or after September 1, 2014 “S”, “T”,“X”, or “V”, “Q1”,
Q2”, or “Q3”. Status code indicators “Q1”, “Q2”, and “Q3” must qualify for separate payment. APC
relative weight x adjusted conversion factor x 0.808workers’ compensation multiplier, pursuant to
Section 9789.30(aa).
UB-04 indicates G026

169. G0260 and 20610 The Claims Administrator “$0.00”
reimbursement for G0260 and
20610 rationale based on “Payment
for this charge is not recommended
per our Utilization Management
Department” and “Denied per
Adjuster”
Provider seeking remuneration for G0260 Status Indicator “T” injection procedure for sacroiliac joint; provision of anesthetic,
steroid and/or other therapeutic agent, with or without arthrography and 20610 , Status Indicator “T”Arthrocentesis, aspiration
and/or injection, major joint or bursa provided on 08/04/2015.
The Claims Administrator “$0.00” reimbursement for G0260 and 20610 rationale based on “Payment for this charge is not
recommended per our Utilization Management Department” and “Denied per Adjuster”
Communication to Provider from Claims Administrator dated March 27, 2015 shows “Modified Utilization Review
Determination & Authorization: Date of Request 03/19/2015, Date of Decision
03/27/2015, Procedure/Treatment: Left Sacroiliac Joint Injection with Fluoroscopy and no IV Sedation, Begin Date: 03/27/2015
Expiration Date: 03/27/2016”
Procedure was authorized by Utilization Review.
Provider billed disputed services as part of an ambulatory surgical center service on a UB04 with by type 0131 –Hospital
Outpatient.
Per OMFS Outpatient Hospital and Ambulatory Surgery Center Fee Schedule effective , status code indicators andAPC Relative
Weights are based on CMS Addendum AA and B effective for date of service on or after January 1, 2015.
Pursuant to Labor Code section 5307.1(g)(2), the Administrative Director of the Division of Workers’ compensation orders that
Title 8, California Code of Regulations, sections 9789.30 and 9789.31, pertaining to Hospital Outpatient Departments and
Ambulatory Surgical Centers Fee Schedule in the Official Medical Fee Schedule, is amended to conform to CMS’ hospital
outpatient prospective payment system (OPPS). The Administrative Director incorporates by reference, the Centers for Medicare
and Medicaid Services' (CMS) Hospital Outpatient Prospective Payment System (OPPS) certain addenda published in the Federal
Register notices announcing revisions in the Medicare payment rates. The adopted payment system addenda by date of service
are found in the Title 8, California Code of Regulations, and Section 9789.39(b). Based on the adoption of the CMS hospital
outpatient prospective payment system (OPPS), CMS coding guidelines and the hospital outpatient prospective payment system
(OPPS) were referenced during the review of this Independent Bill Review (IBR) case.
G0260 code and 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT)
including arthrography when performed , are typically utilized for billing SI Joint Injections performed with radiologic guidance.
However, the surgical CPT code 27096 has an assigned indicator of “B”. The B indicator definition is “May be paid by fiscal
intermediaries/MACs when submitted on a different bill type” and is not paid under OPPS.
A review of the Addendum AA, ASC Covered Surgical Procedures for CY 2014 does not list HCPCS code 27096, but it does

170. list G0260. Addendum B for CY 2014 does not list an APC Relative weight for procedure code 27096 as this code is not
reimbursable under OPPS. However, a relative weight is listed for HCPCS G0260. Therefore, the Provider correctly submitted
HCPCS code G0260 for billing an OPPS anesthetic injection to sacroiliac joint
with fluoroscopic guidance and reimbursement is warranted for the ASC payment rate for HCPCS G0260.
HCPCS code G0260 has the assigned status indicator for this disputed code for 2014 is “T”. T = Significant Procedure, Multiple
Reduction Applies. Paid under OPPS and separate APC payment. HCPCS code G0260 is grouped into APC 0207 Level III Nerve
Injections.
Section 9789.32. Applicability: For Other Services rendered on or after September 1, 2014 to hospital outpatients, the maximum
allowable hospital outpatient facility fees shall be paid according to the OMFS RBRVS.
OMFS § 9789.33 for services rendered on or after September 1, 2014 “S”, “T”,“X”, or “V”, “Q1”, Q2”, or “Q3”. Status code
indicators “Q1”, “Q2”, and “Q3” must qualify for separate payment. APC relative weight x adjusted conversion factor x 1.212
workers’ compensation multiplier, pursuant to Section 9789.30(aa).
§9789.16.5 Surgery –Multiple Surgeries and Endoscopies (f) Multiple Procedures Including Bilateral Surgeries. If any of the
multiple surgeries are bilateral surgeries, consider the bilateral procedure at 150 percent as one payment amount, rank this with
the remaining procedures, and apply the appropriate multiple surgery reductions.
OMFS §9789.30 (b) for services rendered on or after December 1, 2014 , "APC Payment Rate" means CMS' hospital outpatient
prospective payment system rate for Calendar Year 2014.
CPT 20610 Status indicator “T” is subject to MPPR @ 50% of the Primary Procedure G0260.
Based on the aforementioned documentation and guidelines, reimbursment is warranted for G0260 & 20610
G6041, G6045,
G6046, and G6
056
EORs indicate laboratory results
reflecting Provider’s place of
business is required for
determination
and consideration of
reimbursement.
Provider seeking remuneration for G6041, G6045 , G6046, and G6056, and performed on 08/19/2015.
EORs indicate laboratory results reflecting Provider’s place of business is required for determination
and consideration of reimbursement.
Submitted results relating to G0434 chromatographic qualitative (pos/neg) urine drug screen. A Separate set of results with the
Provider’s office address representing HCPCS G6041, G6045, G6046, quantitative
(amount) analyses of barbiturates, codeine, and dihydrocodeinone and G0656 (quantitative ) for Opiate(s), drug and metabolites,
(including nalorphine ), was submitted for review. Report indicted
the following positive results:
Opiates positive @1143.4 ng/ml
Oxycodone positive @ 221.6 ng/ml
HCPCS G6041, G6045, G6046, and G6056 are quantitative tests not inclusive to a chromatographic
Qualitative Drug screening typically performed, G0434.

171. CCR § 9789.50 (a) Pathology and Laboratory: Effective for services after January 1, 2 004, the maximum reasonable fees for
pathology and laboratory services shall not exceed one hundred twenty (120) percent of the rate for the same procedure code in
the CMS' Clinical Diagnostic Laboratory Fee Schedule, as established by Sections 1833 and 18 34 of the Social Security Act (42
U.S.C. §§ 1395l and 1395m) and applicable to California.
Contractual Agreement indicates 90% OMFS.
Based on the aforementioned documentation and guidelines, reimbursement for G6041, G6045, G6046, and G6056 is Indicated
J7324-LT Claims Administrator reimbursed
NDC with rationale “The charge
exceeds the Medi-Cal pharmacy
fees for Workers’ Compensation
prescriptions”
Provider is dissatisfied with reimbursement of J7324-LT, NDC 59676036001 (Orthovisc) for date of service 12/15/2015
Claims Administrator reimbursed NDC with rationale “The charge exceeds the Medi-Cal pharmacy fees for Workers’
Compensation prescriptions”
§9789.13.2. Physician-Administered Drugs, Biologicals, Vaccines, Blood Products: (2) The maximum reimbursement shall be
determined using the “Basic Rate” for the HCPCS code contained on the Medi-Cal Rates file for the date of service.
Authorization for 3 Orthovisc injections to the left
knee was submitted for review. (3) The “Basic Rate” price listed on the Medi-Cal rates page of the Medi
-Cal website for each physician-administered drug includes an injection administration fee of $4.46. This injection administration
fee should be subtracted from the published rate because payment for the injection administration fee will be determined under
the RBRVS
CMS 1500 form indicates NDC 59676036001x 1 unit utilized for joint injection.
J7324 -Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose
Redbook indicates: NDC 59676036001–Orthovisc, 15-mg/1ml, size 2 ml; injection (prefilled syringe)
–J7324 per dose.
Provider’s report documents “Under aseptic conditions, the left knee was injected with 2cc of Orthovisc Lot #N150027B
Expiration: 2017-05-31. The patient tolerated the injection well” on all three dates of service.
Opportunity for Claims Administrator to dispute Eligibility letter was sent on 5/5/2016. A response from the Claims
Administrator was not received for this review.
A copy of a contract was not submitted for this review. EOR reflects a 3% PPO discount to be applied to
reimbursement.
Based on documentation reviewed and guidelines, reimbursement of J7324 (NDC 59676036001) is warranted.

172. L0637 The Claims Administrator denied
service with the following rational:
“In order to review this charge, we
will need a copy of the invoice, ”
citing 5307.1 (e).
Provider seeking remuneration for L0637 Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior
Frame/Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength
Provided By Rigid Lateral Frame/Panels, Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes
Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated Item That Has Been
Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise, for
date of service 05/08/2015.
The Claims Administrator denied service with the following rational: “In order to review this charge, we will need a copy of the
invoice, ” citing 5307.1 (e).
PPO Contractual Agreement regarding DME reimbursement not submit ted for IBR; unable to verify if the document paid cost
for DME is a requirement.
Authorization, dated 05/06/2015, signed by the Claims Administrator indicates L0637 as Authorized.”
LC 5307.1 (e)(4)(b) refers to “dangerous device.”
Business and Professional California Code 4022.“Dangerous drug” or “dangerous device” means any drug or device unsafe for
self-use in humans or animals, and includes the following :
(a)Any drug that bears the legend: “Caution: federal law prohibits dispensing without prescription,” “Rx only,” or words of
similar import.
(b)Any device that bears the statement: “Caution: federal law restricts this device to sale by or on the order of a ____,” “Rx
only,” or words of similar import, the blank to be filled in with the designation of the practitioner licensed to use or order use of
the device.
(c)Any other drug or device that by federal or state law can be lawfully dispensed only on prescription or furnished pursuant to
Section 4006.
There is no indication that the dispensed LSO (lumbosacral orthosis) required a prescription.
§9789.60. Durable Medical Equipment, Prosthetics, Orthotics, Supplies.
(a) For services, equipment, or goods provided after January 1, 2004, the maximum reasonable reimbursement for durable
medical equipment, supplies and materials, orthotics, prosthetics, and miscellaneous supplies and services shall not exceed one
hundred twenty (120) percent of the rate set forth in the CMS’ Durable Medical Equipment, Prosthetics/Orthotics, and Supplies
(DMEPOS) Fee Schedule, as established by Section 1834 of the Social Security Act(42 U.S.C. § 1395m) and applicable to

173. California.
In the absence of the full contractual agreement defining reimbursement for DMEPOS, or information identifying the dispensed
L0637 as a dangerous device as defined by LC 5307.1 (e)(4)(b), reimbursement is indicated pursuant to § 9789.6
L1990 Claims Administrator denied
reimbursement with the following
rational:“
This item is packaged or bundled
into another basic service.”
Provider seeking $585.10 in remuneration for L1990 Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup,
calf band/cuff (double bar bk orthosis), custom-fabricated dispensed to Injured Worker during Hospital Outpatient Surgery on
08/20/2015.
Initial and Final EOR’s indicates the Claims Administrator denied reimbursement with the following rational:“
This item is packaged or bundled into another basic service.”
Documentation reflects a dispensed item that was not part of the actual surgical procedure.
Hospital Outpatient Administrative Rules § 9789.32 (5) The maximum allowable fee for durable medical equipment, prosthetics
and orthotics shall be determined according to Section 9789.60.
Administrative Rules §9789.60.Durable Medical Equipment, Prosthetics, Orthotics, Supplies.(a) For services, equipment, or
goods provided after January 1, 2004, the maximum reasonable reimbursement for durable medical equipment, supplies and
materials, orthotics, prosthetics, and miscellaneous supplies and services shall not exceed one hundred twenty (120) percent of
the rate set forth in the CMS' Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule, as
established by Section 1834 of the Social Security Act (42 U.S.C. § 1395m) and applicable to California.
Opportunity to Dispute communicated to Claims Administrator on 02/01/2016; response not yet received.
Contractual Agreement not submitted for IBR.
Submitted documentation supports fitting, dispensing, and counseling of L1990 orthotics.
Submitted invoice #7 8460l reflects Total Charges of “531.91,” with a “Balance Due” of “292.55.” The “239.36
” deficit reflects a “credit.” Unknown if the credit represents the Provider’s discounted and actual cost for the items;
documentation does not indicate a deposit or pre-payment was provided to vendor.
General Information and Instructions CCR 9789.11(a)(1)(2) Dispensed durable medical equipment: cost (purchase price plus
sales tax plus shipping and handling) plus 50% of cost up to a maximum of cost plus $25.00 not to exceed the provider’s usual
and customary charge for the item.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for L1990

174. L3908-RT-LT
and L1832-LT
Claims Administrator denied codes
indicating “Payment denied/reduced
for absence of precertification/
authorization.
Authorization dated 08/14/2015 indicates “Specific Request: DME Left knee brace, bilateral wrist brace/Approved by Nurse.
Will dispense@ Provider ’ s Office.” Letter also documents “specific service(s) meets established criteria for medical necessity”
§ 9789.60 Durable Medical Equipment, Prosthetics, Orthotics, Supplies.(a) For services, equipment, or goods provided after
January 1, 2004, the maximum reasonable reimbursement for durable medical equipment, supplies and materials, orthotics,
prosthetics, and miscellaneous supplies and services shall not exceed one hundred twenty (120) percent of the rate set forth in the
CMS' Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule, as established by Section 1834
of the Social Security Act (42 U.S.C. § 1395m) and applicable to California.
Authorization does not show specific codes approved. Documentation must support services.
HCPCS Code L1832: Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise.
Supplemental Report reflects “knee and bilateral wrist braces were dispensed today.” No indication of custom fabrication
specific to Injured Worker as submitted HCPCS code L1832 indicates.
Submitted report does not support a customized orthosis
L6034
(Rev Code 0274)
Provider seeking full remuneration for L0635 (Rev Code 0274) Orthotic Device issued to Injured Worker during DRG 460
Surgical Services on 11/18/2013 –11/21/2013.Claims Administrator Reimbursement Rational for L0635: “Reduction is based on
in-patient fee schedule.”
HCPCS L0635: Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral
articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength

175. provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps,
closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment.
§9789.60Hospital Inpatient Service: the cost of durable medical equipment provided for use at home is exempt from the
Inpatient Hospital Fee Schedule. The cost of durable medical equipment shall be paid pursuant to Section 9789.60.
Claims Administrator included separately reimbursable L0635 device into the overall payment for DRG
460.
L0635 device is separately reimbursable.
§9789.22(k)(7):Items requiring a prescription the allowance shall not exceed OMFS rate of 120% of Medicare’s DMEPOS fee
schedule or 120% of the documented paid cost (not to exceed 100% of documented paid cost plus $250.00).
Proof of Paid Cost submitted by Provider for (L0635): $612.81
OMFS allowance for the HCPCS code L0635 is $1,114.20. 
120%
Allowance of the documented paid cost is $735.37

Based on the aforementioned guidelines and documentation, reimbursement for billed
orthotic (L0635) is 120% of the documented paid cost.
Ml Reports 10606. Physicians' Reports as Evidence.
(a) The Workers' Compensation Appeals Board favors the production of medical evidence in the form of written reports. Direct
examination of a medical witness will not be received at a trial except upon a showing of good cause. A continuance may be
granted for rebuttal medical testimony subject to Labor Code Section 5502.5.
(b) Medical reports should include where applicable:
(1) the date of the examination;
(2) the history of the injury;
(3) the patient's complaints;
(4) a listing of all information received in preparation of the report or relied upon for the formulation of the physician's opinion;
(5) the patient's medical history, including injuries and conditions, and residuals thereof, if any;
(6) findings on examination;
(7) a diagnosis;

176. (8) opinion as to the nature, extent, and duration of disability and work limitations, if any;
(9) cause of the disability;
(10) treatment indicated, including past, continuing, and future medical care;
(11) opinion as to whether or not permanent disability has resulted from the injury and whether or not it is stationary. If
stationary, a description of the disability with a complete evaluation;
(12) apportionment of disability, if any;
(13) a determination of the percent of the total causation resulting from actual events of employment, if the injury is alleged to be
a psychiatric injury;
(14) the reasons for the opinion; and,
(15 ) the signature of the physician.
In death cases, the reports of non-examining physicians may be admitted into evidence in lieu of oral testimony.
(c) All medical-legal reports shall comply with the provisions of Labor Code Section 4628. Except as otherwise provided by the
Labor Code, including Labor Code Sections 4628 and 5703, and the rules of practice and procedure of the Appeals Board, failure
to comply with the requirements of this section will not make the report inadmissible but will be considered in weighing the
evidence.
ML100 ISSUE IN DISPUTE: Provider
seeking remuneration for ML100
Missed Med-Legal
Examination Appointment for Date of Service 11/05/2015.
Communication dated 09/09/2015 signed by the Claims Administrator acknowledges fee for missed appointment.
Documentation reflects Injured Worker failed to keep designated appointment.
CCR § 5307.11 : A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee
schedule, the medical fee schedule for
that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the
contracted reimbursement rates.
The aforementioned 09/09/2015 documentation is contractual in nature. As such, the contractual obligations apply pursuant to
LC § 5307.11.
Communication from the Claims Administrator dated 03/08/2016 responding to Opportunity to Dispute Eligibility indicates
acknowledgement of “erroneously denied” ML100 service. The Check Number or a
copy of check was not submitted for IBR and cannot be verified. The DCN reflected on the provided list indicates
“0000000000. ” Without the Claims Administrator’s explanation reflecting DCN of ‘0000000000,” it is unknown if the check has
or has yet to be generated.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for ML100.
ML100 Claims Administrator denied billed
code with indication “Medical
Legal missed appointment code
used for communication purposes
only”
ML 100: Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation. This code is designed for
communication purposes only. It does not imply that compensation is necessarily owed.
Documentation submitted included Agreement Request –Medical Legal Consultation with Provider which states: “
Cancelation/No show fee $350 billed as ML100 (avoid charge with notice prior to 5 business days. ”Document
shows “Approved ” and is signed by Claims Administrator dated 8/18/2015.
Documentation showing cancelation of injured worker within time frame not identified in review.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed

177. pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rates.
Signed document dated 8/18/2015 is contract in nature.
Based on aforementioned documentation and guidelines, reimbursement of ML 100 is warranted
ML101 Claims Administrator reimbursed
$3403.13 from total billed amount
$6187.50 with rationale “excessive
billing, and asserts that
approximately 45% of the 66 page
report includes commentary outside
Provider’s area of expertise
Provider seeking remuneration for ML 101 on date of service 04/14/2015.
Claims Administrator reimbursed $3403.13 from total billed amount $6187.50 with rationale “excessive billing, and asserts that
approximately 45% of the 66 page report includes commentary outside Provider’s area of expertise”
Communication to Provider from Claims Administrator in the form of a letter dated April 8, 2015 states the injured worker “is
being returned to you for a medical-legal evaluation on April 14, 2015 at 10:00am.”Third paragraph
requests “Please re-examine the patient and review the enclosed medical records...provide a supplemental with your medical
opinion regarding issues of permanent disability, causation, apportionment, and future medical care.”
The letter states who will be allowed at this visit which includes the patient, an approved interpreter and the Provider.
The letter does not mention any areas in which the Provider is not to discuss regarding the injured worker in thesupplemental
report nor does the request ask only for the Provider’s “area of expertise.”
Provider’s report documents his opinion of the injured worker’s condition according to the records reviewed as per request from
the Claims Administrator.
Provider’s report documents time spent as:1.Face-to-Face 1 hour 25 minutes
2.Record Review 11 hours 45 minutes
3.Medical Research 2 hours 30 minutes
4.Report Writing 9 hours 0 minutes For a Total time of 24 hours 40 minutes or 99 units.
ML 101: Follow-up Medical-Legal Evaluation. Limited to a follow-up medical-legal evaluation by a physician which occurs
within nine months of the date on which the prior medical-legal evaluation was performed. The physician shall include in his or
her report verification, under penalty of perjury, of time spent in each of the following activities: review of records, face-to-face
time with the injured worker, and preparation of the
report. Time spent shall be tabulated in increments of 15 minutes or portions thereof, rounded to the nearest quarter hour. The
physician shall be reimbursed at the rate of RV 5, or his or her usual and customary fee, whichever is less, for each quarter hour.
Based on information reviewed, additional reimbursement of ML 101 is warranted

178. ML101
-
94
Claims Administrator denied
reimbursement based on “criteria.”
Provider seeking remuneration for ML101-94 services for date of services 06/02/2015.
Claims Administrator denied reimbursement based on “criteria.”
OMFS ML101 definition: Follow-up ML evaluation.
Occurs within nine months of initial ML evaluation.
Involves a physical examination.
The physician must verify, under penalty of perjury, the time spent by him or her on the following activities:
1.review of records
2.face-to-face time with the injured worker
3.preparation of the report (doesn’t include clerical time)
4.Time spent shall be tabulated in 15 minute increments.
Modifier -94 definition: AME evaluation increases fee by 25%.
Submitted evaluation report indicates an initial” AME evaluation on “10/8/2014.” ML101 Follow-up
Examination date is 06/02/15, which is less than nine months of the initial exam of 10/08/2014.
Correspondence from the Claims Administrator to the Provider, received by the Provider on 04/28/2015, indicates
request for QME Evaluation on “Friday, May 22, 2015 @ 9:00 am.”
Subsequent faxed correspondence from Claims Administrator to Provider reflects correction of QME status to AME status and a
new exam date of “6/02/15.”
Aforementioned correspondence indicates the Claims Administrator was seeking a comprehensive exam with
extraordinary circumstances.
ML104, ML103, & ML101 require elements 1–4 as listed above in the definition for ML101.
The submitted 06/02/2015 does not contain the following necessary documentation of time:
1.review of records
2.face-to-face time with the injured worker
Documentation reflects Injured Worker was examined by the Provider on 06/02/2015, however, this face-to-face time cannot be
extrapolated from the submitted report.
3.preparation of the report (doesn’t include clerical time)
4.Time spent shall be tabulated in 15 minute increments.
Since the necessary time elements are not documented in the submitted report to qualify for ML104, ML103
or ML101 services, and the Claims Administrator authorized Med-Legal services, a Med-Legal Exam that reflects the submitted
Med-Legal Report is warranted.
ML102 Definition: A basic medical evaluation which does not meet the criteria of any other medical-legal evaluation. Paid at a
flat rate of $625.00
Based on the aforementioned documentation and guidelines, reimbursement is warranted for ML102-94

179. ML101 The Claims Administrator indicates
ML101 units reduced based on
submitted report.
OMFS Med-Legal ML101 Definition:
Follow-up ML evaluation.
Occurs within nine months of initial ML evaluation.
Involves a physical examination.
The physician must verify, under penalty of perjury, the time spent by him or her on the following activities:review of
recordsface-to-face time with the injured worker preparation of the report (doesn’t include clerical time)
Time spent shall be tabulated in 15 minute increments
All expenses are included except for diagnostic testing.
Submitted Documentation entitled “Supplemental Report” reviewed ; the criteria for ML101 was not met as the Injured Worker
was not re-examined in accordance with ML101.
Authorization and Report reflects ML106 services.
OMFS Med-Legal ML106 Definition:
ML 106 RV 5 Per 15 Min. $62.50/15 min or $250/hr
Fees for supplemental medical-legal evaluations.
Fees will not be allowed under this section for supplemental reports 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 the initial report the results of laboratory or diagnostic tests which were
ordered by the physician as part of the initial evaluation
Authorization for Med-Legal Supplemental Report Services, dated September 9, 2015 signed by Legal Parties substantiates the
need for the Provider’s supplementary services. Allowable hours for the requested services is not indicated.
Page 2, paragraph 2 of the Supplemental Report reflects the following time components:
Reviewing and summarizing report = two hours
Writing Report = three hours Note: Although “summarizing report ” is indicated, the act does not categoricallyinfer the act was
performed during the actual composition (writing) of the report; the action could also reflect time spent during intellectual
contemplation and compartmentalizing of new data pertaining to relevant medical issues relating to the Injured Worker.
Based on the documentation submitted, additional reimbursement for ML101 is not indicated, recommend reimbursement for
documented services ML106.

180. ML101-92 Provider disputing reimbursement for ML101-92. The Claims Administrator changed the submitted code to the following codes:
99080, 99215, 99358, 99354 and 99355, and reimbursed the Provider $499.82 out of the $3,000.00 service charge.
The Provider is seeking additional reimbursement of $2,500.18 from the Claims Administrator.
The CMS 1500 form copy provided indicates the provider billed ML101 -92 on 5/08/2014.
The Claims Administrator changed service code ML101 -92 to codes 99080 (Special Reports), 99215 (Office/Outpatient
E&M), 99358 (Prolonged Services without Pt. contact) , 99354 (Prolonged Services
–1sthour) and 99355 (Prolonged Services –Each Additional 30).
The Claims Administrator did not provide a reason for changing the ML101 –92 to 99080,
99215, 99358, 99354 and 99355.
The OMFS definition for ML101 states the following qualifying factor “ Follow-upMedical-Legal Evaluation. Limited to a
follow-up medical-legal evaluation by a physician which occurs within nine months of the date on which the prior medical-legal
evaluation was performed.”
OMFS Modifier -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.”
The Provider, an Orthopedic Surgeon, was requested by Legal Parties in the matter of (Injured Worker) v. (Employer/Claims
Administrator) to perform afollow-up medical evaluation and render a medical opinion on the Injured Worker.
The formal request to the Provider from the Legal Party is dated April 14, 2014.
The specific request from the above mentioned Legal Party stipulates,“... please provide your comprehensive medical legal
report on each of the disputed issues.”
EOR does not specify validity of ML101 -92; code changed as mentioned earlier.
On May 2, 2014 the Injured Worker was physically evaluated by The Provider for “two hours.”
Per the Legal Party’s request, the Provider addressed the following:
Nature and Extent of Permanent Disability –Addressed on Page 8
Whole Person Impairment (WPI)–Addressed on page8
Apportionment, including if relevant, a Benson analysis –Addressed on pages 13 & 14

181. AOE/COE –Addressed on pages 10 through 14.
TTD Status –Addressed on pages 14 through 18.
TPD Status –N/A (refer to pages 14 thorough 18 under TTD)
Provider states, page 1 of the QME report, “Twelve hours were required to review all relevant records, re-examine the patient,
and prepare this report.”
ML 101 -RV 5 Per 15 Min. $62.50/15 min or $250/hr
12 hours = 48 units
ML10193-95 Provider seeking full remuneration for ML101-93-95 services performed on 05/05/2014.
The Claims Administrator reimbursement rational: “Charge has been adjusted to the scheduled fee schedule allowance.”
Amount Billed: $2,268.75
Amount Reimbursed: $2,062.50
Claims Administrator not disputing ML101 service.
Modifier -93: Interpreter -Applicable to ML102 and ML103 Services.
Modifier -93: Interpreter –Not Applicable to ML101 service.
Modifier -95: QME. No change in fee.

182. Time Component, Page 2 of QME report Provider states, “8.25 hours”
8.25 hours = 33 Units.
33 units reflected on CMS 1500 form for date of service 05/02/2014.
33 x $62.50 =$2,062.50 Provider seeking full remuneration for ML101-93-95 services performed on 05/05/2014.
The Claims Administrator reimbursement rational: “Charge has been adjusted to the scheduled fee schedule allowance.”
Amount Billed: $2,268.75
Amount Reimbursed: $2,062.50
Claims Administrator not disputing ML101 service.
Modifier -93: Interpreter -Applicable to ML102 and ML103 Services.
Modifier -93: Interpreter –Not Applicable to ML101 service.
Modifier -95: QME. No change in fee.
Time Component, Page 2 of QME report Provider states, “8.25 hours”
8.25 hours = 33 Unit.
33 units reflected on CMS 1500 form for date of service 05/02/2014.
33 x $62.50 =$2,062.50
ML101-94, 96100 EOR 11/19/2013 reflects
reimbursement by Claims
Administrator in the amount of
$168.24. Reimbursement rational:
“Amounts billed above the payment
or the recommend allowances as
shown, are hereby objected to as
being in excess of amounts
authorized under Labor Code...”
Provider seeking full remuneration for Follow-Up ML101-94 Evaluation and 96100 Psychological testing performed on
10/19/2013.
EOR 11/19/2013 reflects reimbursement by Claims Administrator in the amount of $168.24. Reimbursement rational: “Amounts
billed above the payment or the recommend allowances as shown, are hereby objected to as being in excess of amounts
authorized under Labor Code...”
EOR 06/14/2014 reflects reimbursement by Claims Administrator in the amount of $167.85. Reimbursement rational: “Amounts
billed above the payment or the recommend allowances as shown, are hereby objected to as being in excess of amounts
authorized under Labor Code...”
OMFS ML101: “Limited to a follow-up medical-legal evaluation by a physician which occurs
within nine months of the date on which the prior medical-legal evaluation was performed. The physician shall include in his or
her report verification, under penalty of perjury, of time spent in each of the following activities: review of records, face-to-face
time with the injured worker, and preparation of the report. Time spent shall be tabulated in increments of 15 minutes or portions
thereof, rounded to the nearest quarter hour. The physician shall be reimbursed at the rate of RV 5, or his or her usual and
customary fee, whichever is less, for each quarter hour.”
Date of service 10/19/2013 is “within nine months” of initial exam of March 25, 2013 as indicated in the 10/19/2013 QME
report.
OMFS Modifier -94: “25%” Increase

183. 09/12/2013 Authorization from Legal Parties addressed to the Provider confirms re-evaluation of Injured Worker on 10/19/2013
and refers to the Provider as Panel QME.
Initial EOR for Initial Exam not available. As such, confirmation as to the Claims Administrator’s acceptance (reimbursement)
of Modifier -94 cannot be verified.
DWC QME and AME Fact Sheet “If you have an attorney, your attorney and the claims administrator may agree on a doctor
without using the state system for getting a QME. The doctor they agree on is called an AME. If they cannot agree, they must ask
for a QME.”
Initial March 25, 2013 ML Exam not available for IBR. As such, verifying if the record review included records that were
unavailable to the provider at the time of the initial exam cannot be verified.
CPT 96101: Psychological Testing, Including Interpretation, per hour. i.“2.00,” indicated on page 2 of QME report.
EOR 06/04/2013 reflect $187.83 reimbursement for 96101
EOR 01/26/2014 reflect additional payment of $13.32 for 96101
ML101 Criteria: i.Review of Records: “5.00,” indicated on page 2 of QME report .ii. Face to Face Time: “2.00,” indicated on
page 2 of QME report. iii.Preparation of Report: “5:00,” indicated on page 2 of QME Report. iv.Units = 48x Med-Legal OMFS
$62.50
ML101-95 Claims Administrator denied
services indicating: “Provider does
not participate in MPN.”
Provider disputing $0.00 reimbursement for ML101-95 services performed on 01/20/2014.
Claims Administrator denied services indicating: “Provider does not participate in MPN.”
ML101Med. Legal Definition: “Follow-up Medical-Legal Evaluation. Limited to a follow-up medical
-legal evaluation by a physician which occurs within nine months of the date on which the prior medical
-legal evaluation was performed
Modifier-95 Med. Legal Definition: “Evaluation performed by a panel selected Qualified Medical Evaluator.”
MPN, Multiple Provider Network, is not relevant to Authorized Medical Legal Services.
Authorization dated December 27, 2013 from (Legal Parties) confirms Provider’s “QME” status as a “Panel Qualified Medical
Examiner.”
Provider is a Qualified Medical Examiner under California Labor Code Section 139.2.
Authorization for Physician to “re-examine” Injured Worker and additional records. Authorization specifically asks Provider to

184. “review and incorporate your review of these records into your Panel Qualified Medical Evaluation Report.
Authorization provides the date and time of the Injured Worker’s pre-scheduled appointment, “January 20, 2014 at 10:30 a.m.”
QME re-evaluation report, attestation signed 2/10/14, for DOS 1/20/2014 reflects Injured Worker was re-examined by Provider.
Monday, August 19th, 2013 (Initial QME Exam as per documentation) and Monday, January 20th, 2014 is 154 days. This is
equal to 5 months and 1 day.
Abstracted Information and time frame qualifies for ML101-95 service.
13units indicated = $812.50 Due Provider for ML101-95 services.
ML101-95 Claims Administrator denied
services indicating: “Payment
denied/reduced for absence of, or
exceeded, pre-
certification/authorization.”
Provider disputing $0.00 reimbursement for ML101-95 services performed on 08/04/2015.
ML101 Med. Legal Definition: “Follow-up Medical-Legal Evaluation. Limited to a follow-up medical-legal evaluation by a
physician which occurs within nine months of the date on which the prior medical-legal evaluation
was performed
Modifier-95 Med. Legal Definition: “Evaluation performed by a panel selected Qualified Medical Evaluator.”
Authorization dated June 2, 2015 from (Legal Parties) confirms Provider’s “QME” status as a “Panel Qualified Medical
Examiner,” and re-evaluation date of 08/04/2015.
Provider is a Qualified Medical Examiner under California Labor Code Section 139.2.
Authorization for Physician to “re-examine” Injured Worker and additional records. Authorization specifically asks Provider to
advise parties in the following areas:
Causation
Diagnosis
Periods of TTD or/and T.P.DD; P&S date Impairment discussion and impairment percentage (please include and
Almaraz/gusman discussin to acertain most accurate W.P.I.).
Apportionment (for defendant)
Need for continuing or future medical care.
November 18, 2014 (Initial QME Exam as per documentation) to August 3, 2015 is 261days. This is equal to 8
months and 19 days which is less than 9 month time frame for ML101 reporting.
Abstracted Information and time frame qualifies for ML101-95 service.
13 units indicated = $812.50 Due Provider for ML101-95 services.
ML101-95, ML104-
95
The Claims Administrator denied
initial ML101-95 reimbursement
with the following rational:
Please remit initial ML report.
Provider seeking remuneration for ML101-95 Follow Up Med/Legal QME examination, ML104 Med-Le
gal QME Exam with extraordinary circumstances, performed on 10/01/2015.
The Claims Administrator denied initial ML101-95 reimbursement with the following rational:
Please remit initial ML report.

185. SBR indicates corrected claim to ML104-95. However, the final EOR indicates “duplicate billing” for ML101, ML104 not
indicated.
As defined by the Med-Legal OMFS, ML101 must meet the following criteria:
Follow-up ML evaluation.
Occurs within nine months of initial ML evaluation.
Involves a physical examination.
The physician must verify, under penalty of perjury, the time spent by him or her on the following activities:
review of records
face-to-face time with the injured worker
preparation of the report (doesn’t include clerical time)
Submitted documentation does not include the full report generated for the Initial Med-Legal Examination. Without
documentation to support the initial Med-Legal evaluation, a “follow-up” status cannot be verified. It is noted on page 8 of the
submitted report a QME exam date of 01/03/2014 is listed,
however, the actual 01/03/2014 report was not submitted. Additionally, the time factor for the 01/03/2014 OME Exam equates to
1 year, 8 months, 28 days which exceeds the 9 month time line for a Med-Legal supplemental report.
SBR indicates corrected claim as ML104. ML104 OMFS Med-Legal relevant code Description: “A comprehensive medical-
legal evaluation for which the physician and the parties agree, prior to the evaluation, that the evaluation involves extraordinary
circumstances.”
Agreement for Med-Legal services not submitted for IBR.
Unable to recommend a Med-Legal Evaluation that would fit the criteria of the submitted report as the
request for QME services listing the objectives for a Med-Legal evaluation was not submitted for IBR.
Unable to recommend Evaluation and Management code as the submitted documentation does not include an authorization from
the Claims Administrator to the Provider for medical evaluation services.
Based on the aforementioned documentation and guidelines, reimbursement is not indicated for ML10
1-95 or ML104-95.

186. ML102 The Claims Administrator based
reimbursement on 99214,
Established Patient Evaluation and
WC004
Primary Treating Physician
Permanent and Stationary Report,
as “more appropriate.”
Provider seeking remuneration for ML102 Med Legal services performed on 02/26/2015.
The Claims Administrator based reimbursement on 99214, Established Patient Evaluation and WC004
Primary Treating Physician Permanent and Stationary Report, as “more appropriate.”
Authorization for ML102 –ML104 services signed by Claims Administrator on 01/15/2015, as “Approved.”
LC § 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health
and Safety Code, and a contracting agent, employer, or carrier contract for
reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health
facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
The aforementioned 01/15/2015 documentation is contractual in nature. As such, the contractual rates apply pursuant to LC §
5307.11. Unless otherwise indicated, PPO discounted rates are not applicable to Med-Legal fee schedule.
ML102 OMFS Definition: A basic medical evaluation which does not meet the criteria of any other medical -legal evaluation
.Paid at a flat rate ($625.00). All expenses are included except for diagnostic testing.
Submitted “Permanent and Stationary Report” reviewed , evaluation provided to Injured Worker on “February
26, 2015,” as sated on page 6 of 9.
Based on the aforementioned documentation and guidelines, reimbursement is supported for ML102

187. ML102-94 and
99499 x8 units
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider is disputing reimbursement for services ML102-94 and 99499; denied in full (or part) by the
Claims Administrator.
ML102-94 : OMFS Definition, “A basic medical evaluation which does not meet the criteria of any other medical-legal
evaluation. Paid at a flat rate. All expenses are included except for diagnostic testing.”
Modifier -94: OMFS Definition, “94 AME evaluation, increases fee by 25%.”
First Bill Review by the Claims Administrator denied the reimbursement for ML102-94 stating, “The charge was denied as the
report/documentation does not indicate that the service was
performed.”
Second Bill Review by the Claims Administrator upheld the first denial stating, “From the documentation received, it appears
that a Permanent &Stationary/MMI Evaluation was
performed which is billable under the OMFS using the appropriate E/M code, Prolonged Service
Code and Report Code.
Authorization from the Injured Worker’s Attorney, dated “March 19, 2013” to the Provider
requested an AME Evaluation on behalf of all involved parties to determine “whether the
Applicant is Permanent & Stationary... if P&S, please address permanent disability, future
medical care, apportionment...”

The OMFS states Permanent & Stationary reports are to be billed by t he “ Primary Treating
Physician” with the “ appropriate E/M code, Prolonged Service Code and Report Code”
The Provider is not the Injured Worker’s Primary Physician. The name of the Primary Physician,
who “sees (Injured Worker) every six weeks,” can be found on page 3 of the “Permanent and
Stationary Status” report.
The Provider Addressed the following: Permanent and Stationary Status , page 6; Factors of
Disability, page 6; Physical Examination Findings page 6; Permanent Impairment Findings page
7; and Apportionment page 7.
Based on the aforementioned guidelines and documentation provided, reimbursement is warranted for ML102-94
CPT 99499: Unlisted evaluation and management service.
OMFS 99499: is a “By Report” code.
Itemized Statement from the provider states 99499 is for “transcription $6.50 x 8 pages.”

188. OMFS Med Legal §9795 (d) states “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.”
CPT 95851 –Range of motion measurements - Listed on Invoice & CMS 1500 (HCFA) Form,
not listed on 2nd Bill Review or IBR Application, not eligible for review.
Based on the aforementioned guidelines and documentation provided, reimbursement is
warranted for 99499
ML102-95-93 Claims Administrator denied code
indicating “the charge was denied as
the report/documentation does not
indicate that the service was
performed”
Communication from legal party to Provider requesting him as PQME with appointment date July 28, 2015.
§ 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a
contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and
revised pursuant to Section 5307.1. When a health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement
rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed
pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted
reimbursement rates.
Communication dated July 28, 2015 is contract in nature.
Provider’s Qualified Medical Evaluation report submit ted documents “Examination started at 10:20 am and ended at 11:23 am”
and “A total of 135 minutes were required to review the records. An additional 190 minutes were required for preparation of this

189. report.”
Report also documents “the assistance of state certified translator” was used during the examination.
-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.
Provider’s report does not detail information described for modifier -93. Therefore, increased value for procedure is not
warranted.
Based on aforementioned guidelines, reimbursement of ML 102-95 is warranted.
ML103-86 Claims Administrator reimbursed
ML 103 as 99205 indicating on the
Explanation of Review “The
documentation does not support the
level of service billed.
Reimbursement was made for a
code that is supported by the
documentation submitted with the
billing”
Provider is seeking remuneration for ML 103 on date of service 03/18/2015.
Claims Administrator reimbursed ML 103 as 99205 indicating on the Explanation of Review “The documentation does not
support the level of service billed. Reimbursement was made for a code that is supported by the documentation submitted with
the billing”
Claims Administrator’s Authorization to Provide Treatment approved “Provider evaluation for AOE/COE”
ML103 Complex Comprehensive Medical-Legal Evaluation. Includes evaluations which require three of the complexity factors
Paid at a flat rate. All expenses are included except for diagnostic testing.
Page 3 of Provider’s report documents “The following complexity factors apply: 1. Addressing the issue of medical causation. 2.
Addressing the issue of apportionment. 3. 2.0 hours of face-to-face time with the patient. 4. 0.25 hours of medical record review.
5. Psychological Evaluation as the primary focus.”
Complexity factors for ML 103 met from Complex Psychological Evaluation include (1) 2 or more hours face
-to-face, (6) Causation and (9) A psychiatric or psychological evaluation.
Based on aforementioned documentation and guidelines ,reimbursement of ML 103 is warranted.
ML103-94 Claims Administrator reimbursed Provider is dissatisfied with reimbursement of ML 103

190. $324.83 after changing ML 103 to
99215 and WC004.
Claims Administrator reimbursed $324.83 after changing ML 103 to 99215 and WC004.
Provider was requested as a Qualified Medical Examiner to evaluate and supply a report “discussing permanent disability, if
any, apportionment, causation, future medical care as well as any periods of temporary total disability.”
Provider’s report documents 1 hour face to face and 3 hours of report preparation. Also found in report, Provider addresses
causation, apportionment, permanent and stationary status and future medical care.
Based on documentation reviewed, reimbursement of ML 103 is warranted.
Provider appended modifier -94, Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator.
Provider performed the evaluation as a QME not AME. Therefore, additional reimbursement for modifier-94 is not warranted.
ML104 Provider seeking remuneration of ML 104 for date of service 06/04/2015
Claims Administrator denied reimbursement with rationale “This workers’ compensation claim has been denied”
Letter dated June 2, 2015 from Legal party to Provider requests services as a Panel Qualified Medical Examiner.
§ 9794. Reimbursement of Medical-Legal Expenses: (a) The cost of comprehensive, follow-up and supplemental medical-legal
evaluation reports, diagnostic tests, and medical –legal testimony, regardless of whether incurred on behalf of the employee or
claims administrator, shall be billed and reimbursed as follows: (2) The cost of comprehensive, follow-up and supplemental
medical-legal evaluations, and medical-legal testimony shall be billed and reimbursed in accordance with the schedule set forth in
Section 9795.
Provider’s report submitted documents: Face-to-face time with patient: 3.5 hours Record Review time: 2.5 hours Medical
Research time: 3.75Report preparation: 7.75 hours Total time: 17.50 hours or 70 units
Opportunity for Claims Administrator to Dispute Eligibility letter was sent on 11/3/2015.
A response from Claims Administrator was not received for this review.
Based on aforementioned, reimbursement of ML 104 is warranted

191. ML104 Provider disputing reimbursement for ML104 Med Legal Psych iatric Evaluation services provided to Injured Worke r on April
10/2014.
Claims Administrator denied the claim stating, “Report document missing, incomplete or invalid; unable to evaluate.”
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h)
"Medical-legal expense" means any costs or expenses incurred by or on behalf of any party or parties, the administrative director,
or the appeals board for X-rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and
as needed, interpreter's fees, for the purpose of proving or disproving a contested claim. The cost of medical evaluations,
diagnostic tests, and interpreters is not a medical-legal expense unless it is incidental to the production of a comprehensive
medical -legal evaluation report, follow-up medical-legal evaluation report, or a supplemental medical-legal evaluation report and
all of the following conditions exist:(1) The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.(2)
The report is obtained at the request of a party
or parties, the administrative director, or the appeals board for the purpose of proving or disproving a contested claim and
addresses the disputed medical fact or facts specified by the party, orparties or other person who requested the comprehensive
medical-legal evaluation report. Nothing in this paragraph shall
be construed to prohibit a physician from addressing additional related medical issues
Letter of Authorization from (Legal Party) dated March 5, 2014 , addressed to Provider, confirming the request for “Psychiatric
Opinions” regarding the following: 1) Diagnosis 2) Medical Treatment required 3) Periods of temporary total psychiatric
disability 4) Permanent disability 5) Causation,6 Apportionment.
Letter of Authorization reflected appointment date of “April 10, 2014.”
QME report dated May 1, 2014 appears to be for April 10, 2014,visit.
Signed QME Form 111 “Qualified or Agreed Medical Evaluator’s Findings Summary,”
singed by Provider on May 5, 2014 indicates exam performed on April 10, 2014.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met, Provider States “125 min” (2 Hours)
(2) 2 or more hours Record Review –Criteria Met,Provider states, “305 min.” (5 Hours)
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “ An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Not Met–in accordance with §9793(j):
"Medical research" is the investigation of medical issues. It includes investigating and reading medical and scientific journals and
texts. "Medical research" does not include reading or reading about the
Guides for the Evaluation of Permanent Impairment(any edition), treatment guidelines (including
guidelines of the American College of Occupational and Environmental Medicine), the Labor

192. Code, regulations or publications of the Division of Workers' Compensation (including the
Physicians' Guide), or other legal materials.
(4) “Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors . Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.” Criteria Met.
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met.
(6) Causation–“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if abona fide issue of medical causation is discovered in the evaluation .” Request
for Causation can be found on Authorization, Page 1 issue 5. Criteria Met.
(7) Apportionment –Criteria Not Met,page 20 of QME Report, under heading “Apportionment,” Provider states “deferred.”
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before
June 30, 2013, addressingthe issue of medical monitoring of an employee following a toxic
exposure to chemical, mineral or biologicsubstances;Criteria Not Met.
(9) A psychiatric or psychological evaluationwhich is the primaryfocus of the medical -
legal evaluation.Criteria Met
.

(10)
For dates of injury before December 31, 2012 where the eval
uation that occurs on or
before June 30, 2013, a
ddressing the issue of denial or modification of treatment by the
claims administrator following utilization review under
Labor Code section 4610.
Date of QME 03/27/2014.Criteria Not Met
Three (3)Complexity Factors Abstracted From QME Report.
ML104 Criteria Met: 4, 6 & 9.
Signed attestation by Provider page 21 & 22 of QME Report.
Time Factors:
Face to Face: “125 min” (2 Hours)
Record Review: “305 min.” (5 Hours)
Research: 2 Hours = 0
Report Prep: 435 (7.25 hours)
Total Units = 57 Units (865 reported minutes

193. ML104 Provider disputing reimbursement of Med Legal 104 services charged on 03/20/2014.
The Claims Administrator Down-coded ML104 to codes: 99205 New Patient, Level 4, 99358
Prolonged Services, WC007 Consultation Reports Requested by the Workers' Compensation Appeals Board. The codes were
substituted for the following reason: “Better defining services performed.”
OMFS "Comprehensive Medical-legal Evaluation means “An evaluation of an employee which results in the preparation of a
narrative medical report prepared and attested to in accordance with LC § 4628, any applicable procedures promulgated under LC
§ 139.2, and the requirements of CCR § 10606 And is either: performed by a Qualified Medical Evaluator pursuant to LC § 139.2
(h), (a panel QME) or performed by a QME, Agreed Medical Evaluator (AME), or the primary treating physician (PTP) for the
purpose of proving or disproving a contested claim, and which meets the criteria found under the definition of “medical-legal
expense. The report is prepared by a physician, as defined by LC § 3209.3.
The report is obtained at the request of: a party or parties, the AD, the WCAB for the purpose of proving or disproving a
contested claim and addresses the disputed medical fact or facts specified by
the party, or parties or other person who requested the comprehensive medical-legal evaluation report.”
Authorization from Legal Party addressed to Provider dated 01/20/2014 requesting Psychiatric Consultation and “any non-
invasive testing (deemed necessary)” to provide a “medical opinion” specifically addressing eight (8) issues including, but not
limited to, “Causation and Apportionment.”
ML104 Criteria Met with the following: 1) Face-to-Face time 2) Record Review 3) Causation and 4)
A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
56 page AME Report dictated by the Provider supports that the Provider performed the requested services listed on the
Authorization.
Causation can be found on page 54
Psychiatric Impression Axis I through V with current GAF score can be found on page 52.
Disability Status, page 54 & 55
Treatment Considerations, page 56
Vocational Rehabilitation, Page 57
OMFS AME (Agreed Medical Evaluator) Modifier -94 increases services by 25%.
Time Spent by Physician as listed on “Explanation of Billing” Attestation of report; Face-to-face time = 3.75 hours; Record
Review = 8.25 hours, Report Preparation = 9.75 hours.

194. 21.75 total hours = 87 units x Med Legal OMFS x AME Modifier -94
ML104 Claims Administrator denied
reimbursement based on the
following rational: “Not a work
related injury/illness and thus not
the liability of the workers’
compensation carrier.”
Provider seeking remuneration for ML104-95 PQME performed on Injured Worker on 04/03/2014.
Claims Administrator denied reimbursement based on the following rational: “Not a work related injury/illness and thus not the
liability of the workers’ compensation carrier.”
Total Billed Charges: $10,000.00
Provider Reimbursed: $0.00
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h) "Medical
-legal expense" means any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the
appeals board for X-rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and as
needed, interpreter's fees, for the purpose of proving or disproving a contested claim. The cost of medical evaluations, diagnostic
tests, and interpreters is not a medical-legal expense unless it is incidental to the production of a comprehensive medical-legal
evaluation report, follow-up medical-legal evaluation report, or a supplemental medical-legal evaluation report and all of the
following conditions exist:(1) The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.(2) The
report is obtained at the request of a party or parties, the administrative director, or the appeals board for the purpose of proving
or disproving a contested
claim and addresses the disputed medical fact or facts specified by the party, or parties or other person who requested the
comprehensive medical-legal evaluation report
Nothing in this paragraph shall be construed to prohibit a physician from addressing additional related medical issues
Letter of Authorization singed by both Applicant and Defendant Legal Parties dated March 28, 2014, addressed to Provider,

195. confirming the request for PQME for April 3, 2014.
Date of Actual Patient Exam: 04/03/2014 as reflected on examination report.
Submitted Service Date on CMS 1500 form: 04/03/2014.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met, Provider States “5.0.”
(2) 2 or more hours Record Review –Criteria Met, Provider states, “17.5 Hrs.”
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon” –
in accordance with §9793 (j): "Medical research" is the
investigation of medical issues. It includes investigating and reading medical and scientific journals and texts. "Medical research"
does not include reading or reading about the Guides for the Evaluation of Permanent Impairment (any edition), treatment
guidelines (including guidelines of the American College of Occupational and Environmental Medicine), the Labor Code,
regulations or publications of the Division of Workers' Compensation (including the Physicians' Guide), or other legal materials
.” Criteria
Met, Page 96 –99, Works Cited Appendix B of QME Report, Excerpts and Medical Evidence throughout report.
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.”Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .” Request for Causation can be found on Authorization,
Page 1, issues 6. Criteria Met
(7) Apportionment –Criteria Met, page 53 of PQME Report, “35%.”
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances;Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610.Date of QME 04/03/2014.Criteria Not Met,
Five (5) Complexity Factors Abstracted From QME Report.
PQME report meets the criteria for ML104
ML104 –Attestation pursuant to §9795, Reasonable Level of Fees for Medical-Legal Expenses
and CLC §139.3, included in Examination Report, page 54 of PQME Report
Modifier 95:PQME, no change in reimbursement
Time Factors:
Face to Face: 5.0 hours = 20 Units
Record Review: 17.5 Hours = 70 Units
Research: 20.5 Hours = 82 Units
Provider indicates “42 hours”
Units = 168
96101 -25, Psychological testing per hour not eligible for review as not indicated on 2nd Bill Review

196. ML104 The Claims Administrator denied
ML104 for the following reasons:
“Unauthorized.”
Provider disputing reimbursement of Med Legal 104 services charged on 11/22/2013.
The Claims Administrator denied ML104 for the following reasons: “Unauthorized.”
Authorization from Legal Parties dated 10/23/2013 to Provider indicates the Provider was “selected to examine the Applicant in
the capacity of panel QME...”
Authorization requests the Provider to perform an Exam and to address nine (9) specific issues including Causation and
Apportionment.
Provider addressed the issues as requested and the findings are well document in the provided QME Report.
Complexity Factors Noted: 1) Face-to-Face Time 2) Record Review 3) Causation = ML103
Apportionment not addressed. Provider states, “... discussion of apportionment would not be appropriate at this time.” Med
Legal OMFS Apportionment Definition: Addressing the issue of apportionment, when
determination of this issue requires the physician to evaluate the claimant's employment by three or more employers, three or
more injuries to the same body system or body region as delineated in the Table
of Contents of Guides to the Evaluation of Permanent Impairment (Fifth Edition), or two or more or more injuries involving two
or more body systems or body regions as delineated in that Table of Contents. The Table of Contents of Guides to the Evaluation
of Permanent Impairment (Fifth Edition), published by
the American Medical Association, 2000, is incorporated by reference.
ML104 Complexity Factors have not been met, services indicate ML 103.

Reimbursement Recommended for ML103-94.

197. ML104 Provider is dissatisfied with reimbursement of ML 104 as ML 103
Claims Administrator down coded ML 104 to ML 103 indicating on the Explanation of Review “
The documentation does not support the level of service billed. Reimbursement was made for a code that is supported by the
documentation submitted with the billing”
ML 103 -In a separate section at the beginning of the report, the physician shall clearly and concisely specify which of the
following complexity factors were required for the evaluation, and the circumstances which made these complexity factors
applicable to the evaluation. An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical evidence relied upon:
(1) Two or more hours of face-to-face time by the physician with the injured worker;
(2) Two or more hours of record review by the physician;
(3) Two or more hours of medical research by the physician;
(4) Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this
combination shall not also be used as the third required complexity factor;
(5) Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors;
(6) Addressing the issue of medical causation, upon written request of the party or parties requesting the report;
(7) Addressing the issue of apportionment, when determination of this issue requires the physician to evaluate the claimant's
employment by three or more employers, three or more injuries to the same
body system or body region as delineated in the Table of Contents of Guides to the Evaluation of Permanent Impairment (Fifth
Edition), or two or more or more injuries involving two or more body systems or body regions as delineated in that Table of

198. Contents.
Provider’s report submitted documents 2 ½ hours face to face with the patient, 70 hours reviewing 18 inches of medical record
review. Medical Research was not identified and report preparation does not count as a complexity factor. Causation was
addressed however, Apportionment was not.
Complexity factor #3 requires a combination of the three factors, face to face time, record review and medical research. As
Provider does not document medical research, complexity factor #4 along with
#6 for Causation are the appropriate factors to determine the correct level of reimbursement as ML 103.
ML104 Claims Administrator denied
reimbursement with rationale “This
workers’ compensation claim has
been denied”
Provider seeking remuneration of ML 104 for date of service 06/04/2015
Claims Administrator denied reimbursement with rationale “This workers’ compensation claim has been denied”
Letter dated June 2, 2015 from Legal party to Provider requests services as a Panel Qualified Medical Examiner.
§ 9794. Reimbursement of Medical-Legal Expenses: (a) The cost of comprehensive, follow-up and supplemental medical-legal
evaluation reports, diagnostic tests, and medical-legal testimony, regardless of whether incurred on behalf of the employee or
claims administrator, shall be billed and reimbursed as follows: (2) The cost of comprehensive, follow-up and supplemental
medical-legal evaluations, and medical-legal testimony shall be billed and reimbursed in accordance with the schedule set forth in
Section 9795.
Provider’s report submitted documents:
Face-to-face time with patient: 3.5 hours
Record Review time: 2.5 hours
Medical Research time: 3.75
Report preparation: 7.75 hours
Total time: 17.50 hours or 70 units
Opportunity for Claims Administrator to Dispute Eligibility letter was sent on 11/3/2015.
A response from Claims Administrator was not received for this review.
Based on aforementioned, reimbursement of ML 104 is warranted.

199. ML104 Claims Administrator denied ML
104 with rationale “Claim is denied.
No payment will be made.”
Communication letter dated July 30, 2015 from legal party stating Provider as Panel Qualified Medical Examiner for date of
service September 3, 2015.
ML 103: Complex Comprehensive Medical-Legal Evaluation. Includes evaluations which require three of the complexity
factors set forth below .In a separate section at the beginning of the report, the physician shall clearly and concisely specify which
of the following complexity factors were required for the evaluation, and the circumstances which made these complexity factors
applicable to the evaluation.
An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical evidence relied upon
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
-(1) Two or more hours of face-to-face time by the physician with the injured worker; 5 hours and 30 minutes -(2) Two or more
hours of record review by the physician; 17 hours-(3) Two or more hours of medical research by the physician; Not Met-
(4) Four or more hours spent on any combination of two of the complexity factors (1) -(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor; Criteria Met–Provider documents 5 hours
and thirty minutes face -to-face with the patient and seventeen hours of record review-
(5) Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors;-
(6) Addressing the issue of medical causation, upon written request of the party or parties requesting the report; Not Requested .-
(7) Addressing the issue of apportionment: Criteria Met on page 87 of Provider’s report.-
(8) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met-
(9) Where the evaluation is performed for injuries that occurred before January 1, 2013 , concerning a dispute over a utilization
review decision if the decision is communicated to the requesting physician on or before June 30 2013, addressing the issue of
denial or modification of treatment by the claims
administrator following utilization review under Labor Code section 4610.N/A
Three (3) complexity factors are supported by Provider’s report.
ML 104 Comprehensive Medical-legal Evaluation Involving Extraordinary Circumstances: (1) An evaluation which requires
four or more of the complexity factors listed under ML 103: Not Met (2)
An evaluation involving prior multiple injuries to the same body part or parts being evaluated, and which requires three or more
of the complexity factors listed under ML 103: Not Met (3) A comprehensive medical-legal evaluation for which the physician
and the parties agree, prior to the evaluation , that the evaluation involves extraordinary circumstances: Not Met
Pursuant §9795, report submit ted does not qualify as ML 104, however, report does qualify as ML 103.

200. ML104 Claims Administrator reimbursed
ML 104 as ML 103 with rationale
“services rendered appear to be best
described by this code”
After much research for Provider’s Fictitious Business Name, IBR was able to identify Provider’s FBN which
shows filed March 14, 2013 and showing an expiration date five years from the date on which it was filed.
According to 2415:2415. (a) Any physician and surgeon or any doctor of podiatric medicine, as the case may be, who as a sole
proprietor, or in apartnership, group, or professional corporation, desires to practice under any name that would otherwise be a
violation of Section 2285 may practice under that name if the proprietor, partnership,
group, or corporation obtains and maintains in current status a fictitious-name permit issued by the Division of Licensing, (which
Safety Works Inc. does hold) or, in the case of doctors of podiatric medicine, the California Board of Podiatric Medicine, under
the provisions of this section.
Communication from Claims Administrator to Provider, dated September 18, 2015 requesting Provider as a Panel Qualified
Medical Evaluator for the injured worker on October 8, 2015.
Provider documents 1 hour face-to-face with the applicant, 2 hours on record review, 2 hours on medical research, and 12.5
hours on report preparation for a total of 17.5 hours and 15 minutes.
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Not Met –in accordance with §9793 (j): "Medical research" is the investigation of medical issues. It includes
investigating and reading medical and scientific journals and
texts. "Medical research" does not include reading or reading about the Guides for the Evaluation of Permanent Impairment (any
edition), treatment guidelines (including guidelines of the American College of Occupational and Environmental Medicine), the
Labor Code, regulations or publications of the Division of Workers' Compensation
(including the Physicians' Guide), or other legal materials.”
Based on aforementioned guidelines, Medical Research is not considered a factor in this case.
Abstracted from Provider’s Qualified Medical Evaluation report: Causation and Apportionment.Report qualifies as ML 104.
Four (4) complexity factors necessary for ML 104 and were identified in Provider’s report.
Based on aforementioned documentation, reimbursement of ML 104 is warranted.

201. ML104
-
95
Claims administrator down coded
ML 104 to ML 103 indicating on
the Explanation of Review “Billing
greater than Medical Legal
Allowance” and “Qualified Medical
Examiner”
Claims administrator down coded ML 104 to ML 103 indicating on the Explanation of Review “Billing greater than Medical
Legal Allowance” and “Qualified Medical Examiner”
The description of Medical-Legal code ML104 is "Comprehensive Medical-Legal evaluation involving extraordinary
circumstances." The criteria for ML104 requires four or more of the ten complexity factors listed under ML103 to be met and
documented by the Provider. The description of modifier 95 is "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." The description of Medical-Legal code ML103 is "Complex
comprehensive Medical-Legal evaluation." The criteria for ML103 requires three of the ten complexity factors to be met and
documented by the Provider.
The Medical-Legal report submitted by the provider met the required four complexity factors. The provider documented four or
more hours of record review and face-to-face time, which qualifies as two complexity factors. The provider addressed the issue of
causation in the report. Addressing the issue of causation qualifies as one factor. The fourth complexity factor was met by the
documentation of a psychological evaluation. The provider specified at the beginning of the report four complexity factors were
met and documented in the Medical-Legal report. Although the combined face-to-face and record review do not total greater than
6 hours, the provider does address Causation and this is a psychiatric evaluation. Therefore, a total of four (4) complexity factors
are met which qualifies this Medical Legal as a ML 104.
The documentation submitted supports the reimbursement of Medical-Legal code ML104 Modifier 95. The code assignment of
ML103 paid by the Claims Administrator was inappropriate.
Based on information reviewed, additional reimbursement of ML 104-95 is warranted.
ML104 Claims Administrator denied
services with the following rational:
“No Reimbursement was made for
the E/M services as the
documentation does not support a
Provider seeking remuneration for ML104 Med Legal services provided to Injured Worker on 09/18/2014.
Claims Administrator denied services with the following rational: “No Reimbursement was made for the E/M services as the
documentation does not support a separate significant identifiable E&M service performed with other services provided. Plan
Procedures not followed.”
Total Billed Charges: $1,687.50

202. separate significant identifiable
E&M service performed with other
services provided. Plan Procedures
not followed.”
Provider Reimbursed: $0.00
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h) "Medical-legal expense" means
any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the appeals board for X-rays,
laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and as needed, interpreter's fees, for
the purpose of proving or disproving a contested claim. The cost of medical evaluations, diagnostic tests, and interpreters is not a
medical-legal expense unless it is incidental to the production of a comprehensive medical-legal evaluation report, follow-up
medical-legal evaluation report, or a supplemental medical-legal evaluation report and all of the following conditions exist: (1)
The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code. (2) The report is obtained at the request of
a party
or parties, the administrative director, or the appeals board for the purpose of proving or disproving a contested claim and
addresses the disputed medical fact or facts specified by the party, or parties or other person who
requested the comprehensive medical-legal evaluation report. Nothing in this paragraph shall be construed to prohibit a physician
from addressing additional related medical issues
Letter of Authorization from (Legal Party) dated 08/13/2014, addressed to “Panel Qualified” Provider, confirming the request
for a “comprehensive narrative report ” addressing the following issues:
1.Diagnosis, Bases and Causation
2.Temporary Disability
3.Permanent and Stationary/Maximum Medical Improvement Status
4.Permanent Disability
5.Apportionment
6.Future Medical Care
7.Return to Work Issues.
Authorization for “any additional testing” also provided in letter.
Date of Actual Patient Exam: 09/18/2014 as reflected on examination report.
Submitted Service Date on CMS 1500 form: 09/18/2014
QME Documentation compared to ML104 OMFS criteria reflects “4 or more complexity factors” have been met.
Correspondence received from Claims Administrator 01/06/2015 indicates dispute “informally resolved.”However,
EOR within aforementioned correspondence does not indicate payment made to Provider. Additionally, correspondence from the
Provider regarding settlement of dispute not yet received during IBR.
ML104 Time Factors:
Face to Face: .75 hours = 3Units
Record Review: 6Hours = 24Units
ML104 and 96101 Claims Administrator denied codes
indicating on the Explanation of
Review “Claim is denied. No
payment will be made”
ISSUE IN DISPUTE: Provider is dissatisfied with denial of codes ML 104-94 and 96101
Claims Administrator denied codes indicating on the Explanation of Review “Claim is denied. No payment will be made”
Provider was requested by the attorney to perform a Neutral Panel Qualified Medical Evaluation in psychology on letter
submitted dated December 3, 2014.
Provider’s report submitted documents “This examination, psychological testing, review of records, and report preparation
totaled 30.5 hours. This examination entailed 3.5 hours of face to face evaluation and test administration with the applicant, 1
hour of scoring and interpreting psychological tests and questionnaires, 20 hours in the review of medical records and related
documentation that was submitted for review; and 6 hours in the preparation of this report”
Provider also addresses Causation which qualifies as a level ML 104. Provider was not requested as an Agreed Medical
Evaluator therefore, modifier -94 is not appropriate to bill with ML 104.

203. Provider also billed code 96101 x 4 units.
96101 -Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time
administering tests to the patient and time interpreting these test results and preparing the report
Provider does list tests performed with the injured worker, however, time units are not mentioned for each test given. Provider
does mention his “1 hour of scoring and interpreting psychological tests and questionnaires” and therefore warrants 1 unit of
96101. Based on information reviewed, reimbursement of ML 104 and 96101 is warranted. The table below describes the
pertinent claim line information.
ML104 and 96101 The Claims Administrator denied
reimbursement pending
documentation
Provider seeking remuneration for ML104-94-95 and 96101 submitted for date of service 03/20/2015.
The Claims Administrator denied reimbursement pending documentation.
Authorization from Legal Parties to Provider confirms request for “Panel QME,” services, relating to ““psych issues.”
The following requests are noted on the 03/03/2015 Authorization:
Psychological Evaluation
Perform any diagnostic tests necessary.
Address 7direct issues/questions/concerns including:
Causation
Apportionment
ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity factors...”
Med Legal OMFS ML104 criteria when compared to abstracted information provided on the Fee Disclosure
and QME Report revealed the following:
1.Two or more hours of face-to-face time by the physician with the injured worker. “1hours 1 minute.” Criteria Not Met
2.Two or more hours of record review by the physician “3.0 hours.” Criteria Met Research cited pates 41 -533.Two or more
hours of medical research by the physician. Provider indicates “5.5 ours.”CriteriaMet
4.Four or more hours spent on any combination of two complexity factors (1)-(3), which shall count as two complexity factors.

204. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity
factor. Criteria Met
5.Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors.
Criteria Met
6.Addressing the issue of medical causation upon written request of the party or parties requesting the report, or if a bona fide
issue of medical causation is discovered in the evaluation. Criteria Met.
7.Addressing the issue of Apportionment under the following circumstances: Criteria Not Met . Page 35 of PQME Report
Provider indicates Apportionment “deferred.”
LC §4663 (c) In order for a physician's report to be considered complete on the issue of permanent disability, the report must
include an apportionment determination. A physician shall make an apportionment determination by
finding what approximate percentage of the permanent disability was caused by the direct result of injury arising out of and
occurring in the course of employment and what approximate percentage of the permanent disability was caused by other factors
both before and subsequent to the industrial injury, including prior industrial injuries. If the physician is unable to include an
apportionment determination in his or her report, the physician shall
state the specific reasons why the physician could not make a determination of the effect of that prior condition on the permanent
disability arising from the injury. The physician shall then consult with other physicians or refer the employee to another
physician from whom the employee is authorized to seek treatment or evaluation in accordance with this division in order to
make the final determination.
8.Addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic
substances: Criteria Not Met.
9.A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation. Criteria Met
10.Addressing the issue of denial or modification of treatment by the claims administrator following utilization review under
Labor Code section 4610. Criteria Not Met.
Criteria Met for ML104, Units as Follow:
1hour Face-to-Face = 4 units
Activities of Daily Living =Included in Face-to-Face Time and/or Record Review
3hours Record Review = 12 Units
5hours Report Prep = 20 Units
5.5hours Med Research= 22 Units
ML104 Total Units = 58
CPT 96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and
psychopathology, eg, mmpi, rorschach, wais), per hour of the psychologist's or physician's time, both face-to-face time
administering tests to the patient and time interpreting these test results and preparing the report.
Documentation for Psychological Testing is separately identified and is not included in the overall units for
Documented Psychological Testing Hours = 4reimbursable hours (per hour code).
Based on the aforementioned documentation and guidelines, reimbursement is recommended for ML104-95 & 96001

205. ML104 x 38 Provider seeking remuneration for billed Med-Legal ML104-92 services submitted for date of service
12/03/2015.
Claims Administrator denied reimbursement for services with the following rational: “Documentation does not support the level
of service billed.”
Title 8, California Code of Regulations, Chapter 4.5, Division of Workers’ Compensation Subchapter 1, Administrative Director
–Administrative Rules, Article 5.6 Section 9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up,
Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony. (c) Medical-legal evaluation
reports and medical-legal testimony shall be reimbursed as follows: ML104 Procedure Description: A comprehensive medical-
legal evaluation for which the physician and the parties agree , prior to the evaluation, that the evaluation involves extraordinary
circumstances.
Authorization for ML104 services could not be found within the documents submitted for IBR.
Documentation does not include directives from Legal Parties for Med-Legal Services.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Not Met , Page 1, paragraph 4, of QME Report, the
Provider States “thirty minutes was spent in direct face-to-face time with the patient.”
(2) 2 or more hours Record Review–Criteria Met, Page 1, paragraph 5 of QME Report, Provider states,
“combination of 6 hours in addition to face to face time; total time is 5.5 hours of record review.
(3) Two or more hours of medical research by the physician;
•Med. Legal OMFS, “An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical evidence relied upon
” Criteria Not Met §9793 (j): "Medical research" is the investigation of medical issues. It includes investigating and reading
medical and scientific journals and texts. "Medical research" does not include reading or reading about the Guides for the
Evaluation of Permanent Impairment (any edition), treatment guidelines (including guidelines of the American College of
Occupational and Environmental Medicine), the Labor Code, regulations or publications of the Division of Workers'
Compensation (including the
Physicians' Guide), or other legal materials.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3),
which shall count as two complexity factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also
be used as the third required complexity factor.”Criteria Not Met-criteria 3 not reflected in report.
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity

206. factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .” Criteria Not Met
•Directive from Claims Administrator/Legal Parties not received.
•Unable to verify discovery of “bona fide issue of medical causation” as past history or directive from Claims
Administrator/Legal parties was not available for review.
(7) Apportionment –Criteria Not Met. Page 20 of QME report, the Provider indicates, “I cannot provide a definitive opinion on
apportionment until she has reached maximum medical improvement.”
•LC 4663. (a) Apportionment of permanent disability shall be based on causation.(b) Any physician who prepares a report
addressing the issue of permanent disability due to a claimed industrial injury shall in that report address the issue of causation of
the permanent disability.(c) In order for a physician's report to be considered complete on the issue of permanent disability, it
must include an apportionment determination .A physician shall make an apportionment determination by finding what
approximate percentage of the permanent disability was caused by the direct result of injury arising out of and occurring in the
course of employment and what approximate percentage of the permanent disability was caused by other factors both before and
subsequent to the industrial injury, including prior industrial injuries. If the physician is unable to include an apportionment
determination in his or her report, the physician shall state the specific reasons why the physician could not make a determination
of the effect of that prior condition on the permanent disability arising from the injury. The physician shall then consult with
other physicians or refer the employee to another physician from whom the employee is authorized to seek treatment or
evaluation in accordance with this division in order to make the final
determination. (Emphasis added)
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 013, addressing the issue of
medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met
•Directives from Legal Parties not available to confirm psychological evaluation.
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610.
Criteria Not Met,Date of QME 08/24/2014.
One (1)One Complexity Factor Abstracted from QME Report; criteria not Met for ML104 services.
Based on the aforementioned documentation and guidelines, reimbursement for ML104 services is not indicated.

207. ML104,
73110, 72110, 73562,
73030 and 72040
Claims Administrator ML104
reimbursement rational: “FCE Not
Requested,” and “Not Authorized.”
Provider disputing reimbursement for ML104, 73110, 72110, 73562, 73030 and 72040 services performed on 03/27/2014.
Claims Administrator ML104 reimbursement rational: “FCE Not Requested,” and “Not Authorized.”
FCE “Functional Capacity”
ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity factors...”
Time factor relative to ML104 is in dispute.
DOS 03/27/2013 X-ray CPT Codes: 73110, Wrist; 72210, L-2 Spine; 73562, Knee; 73030 Shoulder; and 72040, Neck/Spine.
Notation on QME, Provider states, “I performed plain film x-rays of the cervical spine, BL shoulders and BL wrists,” followed
by interpretation of each.
Authorization dated March 3, 2014 from (Claims Administrator) confirms Provider chosen as “Qualified Medical Examiner.”
Authorization requests Provider to examine Injured Worker in regards to “a dispute with the medical findings of the medical
determination, regarding the following: a) Permanent and stationary status. b) The extent and scope of medical treatment. c) The
employee’s preclusion or likely preclusion from engaging in his usual occupation. d) The level of permanent disability. e) The
existence of new and further disability.
Authorization for Physician to address the following issues: Injury, Diagnosis, Agree/Disagree Treating Physician’s Findings,
Temporary Disability, Permanent and Stationary/Maximum Medical Improvement, Permanent Impairment, Causation,
Apportionment, Medical Treatment, and Permanent Disability pursuant to the 2004
Permanent Disability Rating Schedule
FCE, and X-rays: 73110, 72110, 73562, 73030 & 72040 fall under Medical-Legal Expenses as indicated in §9794
Reimbursement of Medical-Legal Expenses as these services were performed, not for treatment, but as part of the
Medical-Legal evaluation. Rational for the services can be found on the following pages:
i.FCE , page 19
ii.73110, page 18
iii.72110, page 16
iv.73562, page 19
v.73030, page 18
vi.72040, page 16
FCE performed during ML104 evaluation time factor is as follows:
i.Time factor for FCE reported: 3 hours.
ii.Time factor for ML104 reported:
1.Face to Face: 2 hours 30 min + FCE (exam) = 5hours 30min

208. 2.Record Review: 1 hour 15 min.
3.Research: 0 -Criteria Not Met (Med-Legal OMFS -An evaluator who specifies complexity factor (3) must also provide a list of
citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon.)
4.Provider reports 31 hours 30 min of which 30 hours (120 units) are reportable.
5.Signed Attestation by Provider dated 04/23/2014,page 32
ML104-86-92 ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking remuneration for ML104-86-92 services performed on 03/05/2015.
The Claims Administrator based reimbursement on “better defining service, ”99215 Established Patient Evaluation.
ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity factors...”
RFA DLSR 5021 form reflects authorized service signed by the Claims Administrator on 02/13/2015.
For the following services:
Psych Re-evaluation ML104, 4 –6 hours
Psych Testing 96101, 5 –6 hours
RFA does not indicate specific issues to be addressed in the ML104 evaluation.
Complex Psychological Re-evaluation Documentation, beginning on page 4 of the report, compared to ML104 Med-
LegalOMFS “4 or more complexity factor” requirement:
(1) 2 or more hours Face-to-Face time –CriteriaMet, Provider States –“2.0 hours”
(2) 2 or more hours Record Review –Criteria Not Met. Provider states“ no medical records available for my review.”
(3) Two or more hours of medical research by the physician;Med. Legal OMFS, “An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Not Met –in accordance with §9793 (j): "Medical research" is the investigation of medical issues. It includes
investigating and reading medical and scientific journals and texts. "Medical research" does not include reading or reading about

209. the Guides for the Evaluation of Permanent Impairment (any edition), treatment guidelines (including guidelines of the
American College of Occupational and Environmental Medicine), the Labor Code, regulations or publications of the Division of
Workers' Compensation (including the Physicians' Guide), or other legal materials .” Provider states “15 min.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.” Criteria Not Met
 (5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .”
Criteria NotMet–RFA does not indicate causation requested.
(7) Apportionment –Criteria Met
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610.Date of QME 07/26/2014.Criteria Not Met,
3Complexity factors abstracted from Complex Psychological Re-evaluation Documentation.
Med-Legal services were authorized. As such, a California Specific Med-Legal Evaluation Code,
opposed to a HCPCS evaluation and management code, such as re-assigned code 99215, would be a better defining service.
ML103 Complex Comprehensive Medical-Legal Evaluation . Includes evaluations which require three of the complexity
factors Paid at a flat rate.All expenses are included except for diagnostic testing.
Based on the aforementioned documentation and guidelines, reimbursement is not indicated for ML104;
Reimbursement is recommended for documented service ML103
ML104-86-92 The Claims Administrator based
reimbursement on “better defining
Provider seeking remuneration for ML104-86-92 services performed on 03/05/2015.
The Claims Administrator based reimbursement on “better defining service,” 99215 Established Patient Evaluation.

210. service,” 99215 Established Patient
Evaluation
ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity factors...”
RFA DLSR 5021 form reflects authorized service signed by the Claims Administrator on 02/13/2015. For the following
services:
Psych Re-evaluation ML104, 4 –6 hours
Psych Testing 96101, 5 –6 hours
RFA does not indicate specific issues to be addressed in the ML104 evaluation.
Complex Psychological Re-evaluation Documentation, beginning on page 4 of the report, compared to ML104
Med-Legal OMFS “4 or more complexity factor” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met, Provider States –“2.0 hours”
(2) 2 or more hours Record Review –Criteria Not Met. Provider states “no medical records available for my review.”
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Not Met –in accordance with §9793(j): "Medical research" is the investigation of medical issues. It includes investigating
and reading medical and scientific journals and texts. "Medical research" does not include reading or reading about the Guides for
the Evaluation of Permanent Impairment(any edition), treatment guidelines (including guidelines of the American College of
Occupational and
Environmental Medicine), the Labor Code, regulations or publications of the Division of Workers' Compensation (including the
Physicians' Guide), or other legal materials.” Provider states “15 min.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.”Criteria Not Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report , or
if a bona fide issue of medical causation is discovered in the evaluation.” Criteria Not Met–RFA
does not indicate causation requested.
(7) Apportionment –Criteria Met
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met. ,
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.Criteria
Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Date of QME 07/26/2014. Criteria Not Met,
3Complexity factors abstracted from Complex Psychological Re-evaluation Documentation.
Med-Legal services were authorized. As such, a California Specific Med-Legal Evaluation Code, opposed to a
HCPCS evaluation and management code , such as re-assigned code 99215, would be a better defining service.
ML103 Complex Comprehensive Medical-Legal Evaluation. Includes evaluations which require three of the complexity factors
Paid at a flat rate. All expenses are included except for diagnostic testing.
Based on the aforementioned documentation and guidelines, reimbursement is not indicated for ML104; reimbursement is
recommended for documented service ML103

211. ML104-86-92
(ML by PTP)
The Claims Administrator based
reimbursement on “better defining
service,” 99215 Established Patient
Evaluation
Provider seeking remuneration for ML104-86-92 services performed on 03/05/2015.
The Claims Administrator based reimbursement on “better defining service,” 99215 Established Patient Evaluation.
ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity factors...”
RFA DLSR 5021 form reflects authorized service signed by the Claims Administrator on 02/13/2015. For the following
services:
Psych Re-evaluation ML104, 4 –6 hours
Psych Testing 96101, 5 –6 hours
RFA does not indicate specific issues to be addressed in the ML104 evaluation.
Complex Psychological Re-evaluation Documentation, beginning on page 4 of the report, compared to ML104 Med-Legal
OMFS “4 or more complexity factor” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met, Provider States –“2.0 hours”
(2) 2 or more hours Record Review –Criteria Not Met. Provider states “no medical records available for my review.”
 (3) Two or more hours of medical research by the physician; Med. Legal OMFS, “An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Not Met –in accordance with §9793 (j): "Medical research" is the investigation of medical issues. It includes
investigating and reading medical and scientific journals and texts. "Medical research" does not include reading or reading about
the Guides for the Evaluation of Permanent Impairment (any edition), treatment guidelines (including guidelines of the
American College of Occupational and
Environmental Medicine), the Labor Code, regulations or publications of the Division of Workers' Compensation (including the
Physicians' Guide), or other legal materials .” Provider states “15 min.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.” Criteria Not Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .”Criteria Not Met–RFA
does not indicate causation requested.
(7) Apportionment –Criteria Met
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013 addressing the issue of

212. medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.Criteria
Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Date of QME 07/26/2014.Criteria Not Met,
3 Complexity factors abstracted from Complex Psychological Re-evaluation Documentation.
Med-Legal services were authorized. As such, a California Specific Med-Legal Evaluation Code, opposed to
A HCPCS evaluation and management code , such as re-assigned code 99215, would be a better defining service.
ML103 Complex Comprehensive Medical-Legal Evaluation . Includes evaluations which require three of the complexity factors
Paid at a flat rate.All expenses are included except for diagnostic testing.
Based on the aforementioned documentation and guidelines, reimbursement is not indicated for ML104; reimbursement is
recommended for documented service ML103
ML104-92 ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider disputing reimbursement for ML104-92 Med Legal services provided to Injured Worker on
03/27/2014.
Claims Administrator reimbursed Down-coded the service to Evaluation and Management Code 99215, Established Patient, and
California Reporting Code WC004, Primary Treating Physician's Permanent and.Stationary Report based on the following
rational: “The Official Medical Fee Schedule Does Not List This Code. An Allowance has been made for a comparable service.”
Total Billed Charges: $5,125.00
Provider Reimbursed: $345.15
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h) "Medical
-legal expense" means any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the
appeals board for X-rays, laboratory fees, other diagnostic tests, medical
reports, medical records, medical testimony, and as needed, interpreter's fees, for the purpose of proving or disproving a contested
claim. The cost of medical evaluations, diagnostic tests, and interpreters is
not a medical-legal expense unless it is incidental to the production of a comprehensive medical-legal evaluation report, follow-
up medical-legal evaluation report, or a supplemental medical-legal evaluation report and all of the following conditions exist:
(1) The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.(2) The report is obtained at the request

213. of a party or parties, the administrative director, or the appeals board for the purpose of proving or disproving a contested claim
and addresses the disputed medical fact or facts specified by the party, or parties or other person who requested the
comprehensive medical-legal evaluation report. Nothing in this paragraph shall be construed to prohibit a physician from
addressing additional related medical issues
Letter of Authorization from (Legal Party) dated May 30, 2014, addressed to Provider, confirming the request for a
“comprehensive med-legal report pursuant to applicable Labor Code Sections, including 4660, 4061, 4061.5, 4062, 4062.2, 4064,
4610.5, 4620, 4662, 4626, 5307.1 and 5703, as well as CCR 9785 and 9793. Applicant also requested, pursuant to these sections,
that the physician designated above conduct research as necessary, review records, obtain consults, conduct evaluations, and
prepare med
-legal reporting necessary to address all issues the employer has placed in dispute.”
Date of Actual Patient Exam: 03/27/2013 as reflected on examination report.
Submitted Service Date on CMS 1500 form: 03/27/2013
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Not Met, Provider States “1 1/2 hours.”
(2) 2 or more hours Record Review –Criteria Met, Provider states, “10 hours.”
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “ An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Met–in accordance with §9793 (j):
"Medical research" is the investigation of medical issues. It includes investigating and reading medical and scientific journals and
texts. "Medical research" does not include reading or reading about the
Guides for the Evaluation of Permanent Impairment (any edition), treatment guidelines (including guidelines of the American
College of Occupational and Environmental Medicine), the Labor Code, regulations or publications of the Division of Workers'
Compensation (including the Physicians' Guide
), or otherlegal materials Works Cited Page on page 22 of 22 of the QME Report. Exerpts refrences can be found on page 13,
‘pre-existing migraine’ reference and page 18 regarding obesity and BMI. Provider states, “ 2 hours.”
(4)“ Four or more hours spent on any combination of twoof the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.”Criteria Met
(5) “Six or more hours spent on any combination of threecomplexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if abona fide issue of medical causation is discovered in the evaluation
.” Request for Causation can be found on Authorization, Page 1, issue 5. Criteria Met
(7) Apportionment –Criteria Met, page 27 of QME Report.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical -legal evaluation. Criteria Not Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Date of QME 03/27/2014.Criteria Not Met,
Four (4) Complexity Factors Abstracted From QME Report.
ML104 –Attestation pursuant to §9795 Reasonable Level of Fees for Medical-Legal Expenses included
in Examination Report, page 21 of QME Report
Modifier 92: Primary Treating Physician

214. Time Factors:
ace to Face: 1.5 hours = 6 Units
Record Review: 10 Hours = 40 Units
Research: 2 Hours = 8 Units
Report Prep: 7 hours 28 Units
Total Units = 82 Units
ML104-92 Claims Administrator denied
reimbursement for services with the
following rational: “Documentation
does not support the level of service
billed.”
Provider seeking remuneration for billed Med-Legal ML104-92 services submitted for date of service 11/17/2014.
Claims Administrator denied reimbursement for services with the following rational: “Documentation does not support the level
of service billed.”
Title 8, California Code of Regulations, Chapter 4.5, Division of Workers’ Compensation Subchapter 1, Administrative Director
–Administrative Rules, Article 5.6 Section 9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up,
Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony. (c)Medical-legal evaluation reports
and medical-legal testimony shall be reimbursed as follows: ML104 Procedure Description: A comprehensive medical-legal
evaluation for which the physician and the parties agree, prior to the evaluation, that the evaluation involves extraordinary
circumstances.
CMS 1500 form indicates ML104 (DOS 11/17/2014) and 99204 New Patient Evaluation (DOS
09/24/2014).
Note: An established patient is one who has received a professional service from the physician/qualified health care professional
or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same
group practice, within the past three years. (AMA CPT)
Visit Documentation, Page 1, indicates initial visit less than three months prior to disputed service date
11/17/2014.

215. Authorization for ML104 could not be found within the documents submitted for IBR.
IBR application confirms billed ML104 not authorized; box checked “No” for authorized services.
Communication from the Claims Administrator indicates Provider reimbursed for 99214, Established Patient Evaluation
Services, referencing Initial Exam prior to 11/17/2014.
Documentation does not include directives from Legal Parties for Med-Legal Services.
Visit Report Documentation does not reflect referring party/parties for ML104 services.
Visit Report Documentation does not reflect the 11/17/2014 visit resulted “in the preparation of a narrative medical report
prepared and attested to in accordance with LC § 4628, any applicable procedures promulgated under LC § 139.2, and the
requirements of CCR § 10606.Additionally, Page 1 of the submitted report indicates “Permanent and Stationary” report and an
initial visit of 09/24/2014.
The requirements of Med-Legal evaluation on 11/17/2014 could not be established; a procedure code to reflect any Med-Legal
service could not be identified.
Based on the aforementioned documentation and guidelines, reimbursement for ML104 services is not indicated
ML104-92 Provider seeking remuneration for billed Med-Legal ML104 -92 services submitted for date of service 11/17/2014.
Claims Administrator denied reimbursement for services with the following rational: “Documentation does not support the
level of service billed.”
Title 8, California Code of Regulations, Chapter 4.5, Division of Workers’ Compensation Subchapter 1, Administrative Director
–Administrative Rules, Article 5.6 Section 9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up,
Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony. (c)Medical-legal evaluation reports
and medical-legal testimony shall be reimbursed as follows: ML104 Procedure Description: A comprehensive medical-legal
evaluation for which the physician and the parties agree, prior to the evaluation, that the evaluation involves extraordinary
circumstances.
CMS 1500 form indicates ML104 (DOS 11/17/2014) and 99204 New Patient Evaluation (DOS 09/24/2014).
Note: An established patient is one who has received a professional service from the physician/qualified health care professional
or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same
group practice, within the past three years. (AMA CPT) Visit Documentation, Page 1, indicates initial visit less than three months
prior to disputed service date
11/17/2014.
Authorization for ML104 could not be found within the documents submitted for IBR.
IBR application confirms billed ML104 not authorized; box checked “No” for authorized services.
Communication from the Claims Administrator indicates Provider reimbursed for 99214, Established Patient Evaluation

216. Services, referencing Initial Exam prior to 11/17/2014.
Documentation does not include directives from Legal Parties for Med-Legal Services.
Visit Report Documentation does not reflect referring party/parties for ML104 services.
Visit Report Documentation does not reflect the 11/17/2014 visit resulted “in the preparation
of a narrative medical report prepared and attested to in accordance with LC § 4628, any
applicable procedures promulgated under LC § 139.2, and the requirements of CCR § 10606.
Additionally, Page 1 of the submitted report indicates “Permanent and Stationary ” report and an initial visit of 09/24/2014. The
requirements of Med-Legal evaluation on 11/17/2014 could not be established; a procedure code to reflect any Med-Legal service
could not be identified.
Based on the aforementioned documentation and guidelines, reimbursement for ML104 services is not indicated.
ML104-92 (ML by
PTP Requited by
Applicant)
Claims Administrator reimbursed
Down-coded the service to
Evaluation and Management Code
99215, stablished Patient, and
California Reporting Code WC004,
Primary Treating Physician's
Permanent and. Stationary Report
based on the following rational:
“The Official Medical Fee Schedule
Does Not List This Code. An
Allowance has been made for a
comparable service
Provider disputing reimbursement for ML104 -92 Med Legal services provided to Injured Worker on 03/27/2014.
Claims Administrator reimbursed Down-coded the service to Evaluation and Management Code 99215, stablished Patient, and
California Reporting Code WC004, Primary Treating Physician's Permanent and. Stationary Report based on the following
rational: “The Official Medical Fee Schedule Does Not List This Code. An Allowance has been made for a comparable service.”
Total Billed Charges: $5,125.00
Provider Reimbursed: $345.15
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h) "Medical-legal expense" means
any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the appeals board for X-rays,
laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and as needed, interpreter's fees, for
the purpose of proving or disproving a contested claim. The
cost of medical evaluations, diagnostic tests, and interpreters is not a medical-legal expense unless it is incidental to the
production of a comprehensive medical-legal evaluation report, follow-up medical-legal evaluation report, or a supplemental
medical-legal evaluation report and all of the following conditions exist:
(1) The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.
(2) The report is obtained at the request of a party or parties, the administrative director, or the appeals board for the purpose of
proving or disproving a contested claim and addresses the disputed medical fact or facts specified by the party, or parties or other
person who requested the comprehensive medical-legal evaluation report. Nothing in thi
s paragraph shall be construed to prohibit a physician from addressing additional related medical issues
Letter of Authorization from (Legal Party) dated May 30, 2014, addressed to Provider, confirming the request for a
“comprehensive med-legal report pursuant to applicable Labor Code Sections, including 4660, 4061, 4061.5, 4062, 4062.2, 4064,
4610.5, 4620, 4662, 4626, 5307.1 and 5703, as well as CCR 9785 and 9793. Applicant also requested, pursuant to these sections,
that the physician designated above conduct research as necessary, review records,

217. obtain consults, conduct evaluations, and prepare med-legal reporting necessary to address all issues the employer has placed in
dispute.”
Date of Actual Patient Exam: 03/27/2013 as reflected on examination report.
Submitted Service Date on CMS 1500 form: 03/27/2013
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Not Met ,Provider States “1 1/2 hours.”
 (2) 2 or more hours Record Review –Criteria Met, Provider states, “10 hours.”
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “ An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Met–in accordance with §9793 (j): "Medical research" is the investigation of medical issues. It includes investigating
and reading medical and scientific journals and texts. "Medical
research" does not include reading or reading about the Guides for the Evaluation of Permanent Impairment
(any edition), treatment guidelines (including guidelines of the American College of Occupational and
Environmental Medicine), the Labor Code, regulations or publications of the Division of Workers' Compensation (including the
Physicians' Guide), or other legal materials Works Cited Page on page 22 of 22 of the QME Report. Exerpts refrences can be
found on page 13, ‘pre-existing migraine’ reference and page 18 regarding obesity and
BMI. Provider states, “ 2 hours.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as
two complexity factors . Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third
required complexity factor.”Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .” Request for Causation can be found on Authorization,
Page 1, issue 5. Criteria Met
(7) Apportionment–Criteria Met, page 27 of QME Report.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013 addressing the issue of
medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.Criteria
 (10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Date of QME 03/27/2014.Criteria Not Met,
Four (4) Complexity Factors Abstracted From QME Report.
ML104 –Attestation pursuant to §9795 Reasonable Level of Fees for Medical-Legal Expenses included
in Examination Report, page 21 of QME Report
Modifier 92: Primary Treating Physician
Time Factors:
Face to Face: 1.5 hours = 6 Units
Record Review: 10 Hours = 40 Units
Research: 2 Hours = 8 Units
Report Prep: 7 hours 28 Units
Total Units = 82 Unit

218. ML104-93 Claims Administrator denied
services stating “excessive and
unreasonable” charge.
Provider disputing reimbursement for ML104-93 Med-Legal services provided to Injured Worker on
09/18/2013.
Claims Administrator denied services stating “excessive and unreasonable” charge.
Total Billed Charges: $26,062.50
Provider Reimbursed: $0.00
Letter of Authorization from (Legal Party) dated September 13, 2013 , addressed to Provider, confirming the request for
evaluation to address the following (as listed on authorization):
What is the likely cause of her symptoms? What injury is the likely cause of her fibromyalgia if any?
Given the applicant reports her symptoms occurring after the 2d injury, is there medical
support for the conclusion that the 8/28/01, specific incident was the sole or greater cause of her fibromyalgia and/or other
ailment or pathology, if any?
If the CT injury is the cause of the fibromyalgia, which particular body part identifies or confirms its onset? Please Explain.
What is the medical and scientific evidence for your conclusions, if any?
Claims Administrator specific concerns regarding Med-Legal Exam Report are as follows:
Qualifications of Provider
More than one diagnosis referenced/researched/addressed.
Total time spent on face-to-face
Total time spent on record review
Total time spent on research
Evidentiary standing of report
Length of Report
Total time spent report preparation.
Letter of Authorization from (Legal Party) dated September 13, 2013 states copy of authorization submitted to Claims
Administrator.

219.  Evidence from Legal Parties/Claims Administrator contesting the letter of Authorization prior to, or after, 09/18/ 2013, and
before Invoice for Med-Legal Services, could not be found during IBR.
Evidence disputing the Providers Qualifications before 10/17/13 Invoice from Provider for Med-Legal Services could not be
found during IBR.
Evidence of Contractual Agreement between Provider and Claims Administrator for flat rate
reimbursement on Med-Legal Services could not be found during IBR.
Fibromyalgia and its effects on the body as a whole, for example, urinary, psychological, can
be found on pages 213-223.
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h)
"Medical-legal expense" means any costs or expenses incurred by or on behalf of any party or parties, the administrative
director, or the appeals board for X-rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical
testimony, and as needed, interpreter's fees , for the purpose of proving or disproving a contested claim.
The cost of medical evaluations, diagnostic tests, and interpreters is not a medical-legal expense
unless it is incidental to the production of a comprehensive medical-legal evaluation report,
follow-up medical-legal evaluation report, or a supplemental medical-legal evaluation report
and all of the following conditions exist:
(1) The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.
(2) The report is obtained at the request of a party or parties, the administrative director, or
the appeals board for the purpose of proving or disproving a contested claim and addresses
the disputed medical fact or facts specified by the party, or parties or other person who
requested the comprehensive medical-legal evaluation report. Nothing in this paragraph shall
be construed to prohibit a physician from addressing additional related medical issues
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hour’s Face -to-Face time –Criteria Met.
(2) 2 or more hours Record Review –Criteria Met.
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “ An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon ”
Criteria Met–in accordance with §9793 (j):
"Medical research" is the investigation of medical issues. It includes investigating and reading medical and scientific journals
and texts. "Medical research" does not include reading or reading about the
Guides for the Evaluation of Permanent Impairment (any edition), treatment guidelines (including guidelines of the American
College of Occupational and Environmental Medicine) , the Labor Code, regulations or publications of the Division of Workers'
Compensation (including the Physicians' Guide
), or other legal materials.Excerpts and references can be found on page 197 through 236 of the Med
-Legal Report under the heading, “Medical Research.”
(4) “Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.”Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which
shall countas three complexity factors.” Criteria Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if abona fide issue of medical causation is discovered in the evaluation
.” Request for Causation can be found on Authorization, Page 1, issue 5. Criteria Met

220. (7) Apportionment –Criteria Met
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monito ring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical -legal evaluation. Criteria Not Met
 (10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Date of QME 03 /27/2014.Criteria Not Met,
Five (5) Complexity Factors Abstracted From Med-LegalReport.
ML104 –Attestation pursuant to §9795 Reasonable Level of Fees for Medical-Legal Expenses
includedin Examination Report, signed by Provider on page 237 of Med-Legal Report.Modifier -93: Interpreter -Applicable to
ML102 and ML103 services only.
Time Factors as stated on signed attestation:
Face to Face: 6.3 hours = 25.2 Units
Record Review: 97.9 hours = 391.60
Research: As Above
Report Prep: As Above.
Total Units = 417 Units
Documented time intervals page 238 of Med-Legal Report.

221. ML104-94 Claims Administrator
reimbursement rational: “Payment
based on pre-negotiated agreement
for this specific service,” and
“Reimbursement of $3500.00 per
adjusters authorization.”
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE : Provider disputing Med-Legal ML104-94 reimbursement for services performed on 05/20/2013.
Claims Administrator reimbursement rational: “Payment based on pre-negotiated agreement for this specific service,” and
“Reimbursement of $3500.00 per adjusters authorization.”
Authorization, dated May 3, 2013 for Med -Legal services addressed to the Provider, from the Claims “Adjuster,” requesting
“AME” evaluation regarding the following issues: a) Permanent and stationary status b) The extent and scope of medical
treatment & c) the level of permanent disability
May 3, 2013 AME Evaluation Authorization did not reference a contractual agreement /pre-negotiated rate, between the
Provider and Claims Administrator for Med-Legal services.
Letter to IBR dated August 7, 2014 from the Claims Administrator stated the payment for Med-Legal service “should have came
(come) from... with a specific negotiated rate.”

222. As noted, there isa finding of an agreement of a negotiated rate in the documentation presented for IBR.
Authorization for a Med Legal service not in dispute as the Claims Administrator reimbursed the Provider $3,500.00 for
ML104 services. In absence of a Contractual Agreement, IBR must proceed and evaluate and verify the level of service
performed as dictated by Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations.
It appears the Claims Administrator reimbursed the Provider for 56 units of ML104. In absence of a pre
-negotiated contractual rate for this accepted ML104 service, the time factor for ML104 services will be reviewed.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face -to-Face time –Criteria Met, Provider States “2 Hours.” (2) 2 or more hours Record Review –Criteria
Met, Provider states, “ 27.5 Hours.” (3) Two or more hours of medical research by the physician; Med. Legal OMFS, “An
evaluator who specifies complexity factor (3) must also provide
a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Met –Cited non-guideline related sources located in footnotes on page 105 of the AME report in accordance with §9793
5 j of Article 5.6, provider states, “2 Hours.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.” Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count
as three complexity factors.” Criteria Met (6) Causation –“Addressing the issue of medical causation,
upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the
evaluation. Criteria Met -Causation request can be found on page 2 of the
Authorization for Med-Legal services; addressed on page 104 -107 of QME report. (7) Apportionment
–Criteria Not Met, Provider indicates, “Only when the claimant is determined permanent and stationary can apportionment then
be determined.” (8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013,
addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic
substances; Criteria Not Met.(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal
evaluation. Criteria Not Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Date of QME 5/20/2014.Criteria Not Met,
Four (4) Complexity Factor Abstracted From QME Report.
Criteria Met for ML104 service.
Modifier -94: AME Evaluation, Increases fee by 25%.
Time Factors:
Face to Face: 2 Hours = 68 Units
Record Review: 27.5 Hours = 110 Units
Research: 2 Hours = 8 Units
Report Prep: 3.25 Hours 13 Units
Total Units: 139 Units (34.75 Hours) = $8,687.50
Modifier -
94 @ 25% increase = $2,171.00
Provider Charged $10,842.00
Signed Attestation signed by Provider, Page 108 of 108, signed June 13, 2013

223. ML104-94 The Claims Administrator
reimbursed ML 104-94 however,
down-coded total units based on
elements of report.
Provider seeking remuneration for ML104-94 services performed on 01/18/2016.
The Claims Administrator reimbursed ML 104-94 however, down-coded total units based on elements of report.
Authorization from Legal Parties to Provider confirms request for AME services, relating to the field of orthopedics.
The following requests are noted on the October 13, 2015 Authorization:
Address multiple direct issues/questions /concerns including:
Causation
Apportionment
ML104 Med. Legal Definition: “An evaluation which requires four or more of the complexity factors...”
Ml104 (3)(i) (i) a clear, concise explanation of the extraordinary circumstances related to the medical condition being evaluated
which justifies the use of this procedure code, and (ii) verification under penalty of perjury of the total time spent by the
physician in each of these activities: relevant the records,
face-to-face time with the injured worker, preparing the report and, if applicable, any other activities.
Med Legal OMFS ML104 criteria when compared to abstracted information provided on the AME report revealed the
following:
1.Two or more hours of face-to-face time by the physician with the injured worker. Unable to Determine
–Report Reflects “fourteen hours and fifteen minutes in face to face time and in review of medical records.” Actual Face-to-Face
time is unclear. Criteria Not Met.
2.Two or more hours of record review by the physician Unable to Determine –Report Reflects “fourteen
hours and fifteen minutes in face to face time and in review of medical records.” Actual Record Review
time is unclear. Criteria Not Met.
3.Two or more hours of medical research by the physician. Not Indicated –Criteria Not Met
4.Four or more hours spent on any combination of two complexity factors (1) -(3), which shall count as
two complexity factors.
Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity
factor. Criteria Not Met
5.Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors.
Criteria Not Met

224. 6.Addressing the issue of medical causation upon written request of the party or parties requesting the report, or if a bona fide
issue of medical causation is discovered in the evaluation. Criteria Met
.7.Addressing the issue of Apportionment under the following circumstances: Criteria Met.
8.Addressing the issue of medical monitoring of an employee following a toxic exposure to
chemical, mineral or biologic substances: Criteria Not Met.
9.A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met10.Addressing the issue of denial or modification of treatment by the claims administrator following utilization
review under Labor Code section 4610. Criteria Not Met.
ML104 (2) An evaluation involving prior multiple injuries to the same body part or parts being evaluated, and which requires
three or more of the complexity factors listed under ML 103, including
verification under penalty of perjury of the total time spent by the physician in each of these activities:
reviewing the records
face-to-face time with the injured worker
preparing the report
if applicable, any other activities.
Criteria was not met for ML104 services,however would qualify as ML 102.
Based on documentation and guidelines, additional reimbursement of ML 104-94 is not warranted.
ML104-94 Claims Administrator shows an
allowance of $9125.00 on the
Explanation of Review dated
6/17/2014 for ML 104 indicating
“Recommended payment of this
procedure or
supply should be reimbursed only if
pre-authorization has been obtained
by the Claims
Examiner
Provider is dissatisfied with denial of ML 104 -94. Provider states “At the request of the Claims Adjuster we performed a PQME.
Extensive additional records were provided by both parties along with an appointment to re -evaluate the applicant. A 236 page
report was submitted and not paid for. The Claims Examiner stated via 3/6/14 notice she would make a partial payment. This
NEVER happened. The Claims
Examiner did not send the EOR with her note. The Claims Examiner was notified we never received the check via SBR and she
ignored this. The doctor is entitled to be paid for the hours he spent preforming this very difficult evaluation. PQME’s do not
require pre-authorization.”
Claims Administrator shows an allowance of $9125.00 on the Explanation of Review dated 6/17/2014 for ML 104 indicating
“Recommended payment of this procedure or supply should be reimbursed only if pre-authorization has been obtained by the
Claims Examiner.” An allowance of $543.96 for CPT 96101 Provider had billed was also shown on the same Explanation of
Review with explanation “There was no UR procedure/treatment request received.” A copy of the check for $543.96 was
received by Claims Examiner.
Based on review of the report submitted, the complexity of the report was analyzed and compared to Complexity Factors 1-10.
Complexity Factors 4, 6, 7 and 9 were met. ML 104 criteria met: four or more complexity factors.
Complexity factor #4: Criteria Met: 1 & 2 = 42.75 hours in combination of two complexity factors 1- 3. Complexity factor 6:
Addressing this issue of Causation, Criteria met. Beginning on page 233 of the Medical Legal Report. Complexity Factor #7:
Addressing the issue of Apportionment, Criteria Met Refer to Pages 234 –235 of the Medical Legal Report. Complexity factor

225. #9: A psychiatric or psychological evaluation, Criteria Met Refer to Page 13 of the Medical Legal Report. Separate CPT Code
billed in addition to Criteria 9.
Provider billed with a modifier -94 = Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator.
Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.25. No evidence
of a request for an Agreed Medical Evaluator
as described in (3) of ML 104 has been submitted and therefore no additional increase of 1.25 can be reimbursed.
Provider documents time spent: Preparation of written report: 29 hours, however, report preparation is not a complexity factor to
be reimbursed and therefore is not included in the total units; face to face time 3 hours (12 units); and reviewing medical records
39.75 hours (159units) = 171units
ML104-94 Claims Administrator down coded
ML 104 to ML 103 indicating "the
following are not considered factors
or were not met: Record Review”
Request for Agreed Medical Evaluator was not submitted for review.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time: 2 hours of face -to-face time
(2) 2 or more hours Record Review: 1.25 hours of Record Review
(3) Two or more hours of medical research by the physician; Criteria Not Met
(4) Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor. Criteria Met
(5) Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors. Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation.” Criteria Met
(7) Apportionment –CriteriaMet
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation. Criteria
Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Criteria Not Met
Five (5) Complexity Factors Abstracted from AME Report; time spent on report preparation 3.25 for a total of 6.5 for Medical
Legal Evaluation.
Modifier -94: Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator. Where this modifier is
applicable, the value of the procedure is modified by multiplying the normal value by 1.25.

226. Opportunity for Claims Administrator to Dispute Eligibility letter sent on 1/14/2016. A response was not received for review.
Based on documentation reviewed, additional reimbursement for ML 104-94 is warranted.
ML104-94 The Claims Administrator denied
services requesting re-submission
with “ICD.10” coding.
Med-Legal Services do not require ICD.10 coding.
AME request revealed ML104 extraordinary circumstances with causation and specific apportionment requested.
Modifier –94 increases fee by 25%.
AME report reviewed; Causation and Apportionment yet to be determined.
AME Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met, Page 15 of AME Report, the Provider indicates“2 hours.”
(2) 2 or more hours Record Review –Criteria Met, Page 15 of AME Report, the Provider indicates ,“6 hours.”
(3) Two or more hours of medical research by the physician;
•Med. Legal OMFS, “An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical evidence relied upon” Criteria Not Met
(4) “Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.” Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .” Criteria Not Met
•Directive from Claims Administrator/Legal Parties ’request of causation not fulfilled. Page 14 of AME report indicates “I will
issuea definitive opinion regarding causation ion once I have reviewed the medical records. ”
(7) Apportionment –Criteria Not Met
•AME Authorization indicates request of “whole person impairment rating ”if applicant has yet to reach maximal medical
improvement. Apportionment percentage not indicated. Page 14 of AME report, the Provider indicates
“apportionment percentage values along with a detailed rational will be provided when maximum medical improvement has
been established and permanent impairment rating is performed. ”
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation. Criteria Not Met –
Provider’s Specialty is Orthopedic Surgery and Sports Medicine.
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Criteria Not Met, Date of AME 1 0/15/2015.
Two (2) Complexity Factors Abstracted From AME Report.

227. Criteria not met for ML104, recommend reimbursement for documented service ML102.
ML102 - A basic medical evaluation which does not meet the criteria of any other medical-legal evaluation.
Paid at a flat rate.
All expenses are included except for diagnostic testing.
Based on the aforementioned documentation and guidelines, reimbursement is indicated for ML102 and is not indicated for
ML104
ML104-94 and
96100
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider disputing reimbursement for ML104-94 and 96100 Psychological Med Legal services provided
to Injured Worker on 09/12/2013.
Claims Administrator denied reimbursement with the following rational: “Payment is denied as service not authorized.”
Total Billed Charges: $7,349.46
Provider Reimbursed: $0.00
Article 5.6 Medical-Legal Expenses and Comprehensive Medical-Legal Evaluations §9793 (h) "Medical-legal expense" means
any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the appeals board for X-
rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and as needed, interpreter's
fees, for the purpose of proving or disproving a contested claim . The cost of medical evaluations, diagnostic tests, and
interpreters is not a medical-legal expense unless it is incidental to the production of a comprehensive medical-legal evaluation
report, follow -up medical-legal evaluation report, or a supplemental medical
-legal evaluation report and all of the following conditions exist:
(1) The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.
(2) The report is obtained at the request of a party or parties, the administrative director, or the appeals board for the purpose of
proving or disproving a contested claim and addresses the disputed medical fact or facts specified by the party, or parties or other
person who requested the comprehensive medical
-legal evaluation report. Nothing in this paragraph shall be construed to prohibit a physician from addressing additional related
medical issues
Letter of Authorization from Defendant and Applicant Legal Parties dated (no date indicated), addressed to Provider, confirming
the request for a Provider was “ selected as the Qualified Medical Evaluator
from a panel provided by the Medical Unit...”

228. Letter of Authorization provided the Provider with “authority to perform all tests believed necessary.”
Division of Workers’ Compensation QME and AME Fact Sheet: “What’s the difference between a QME and an AME? If you
have an attorney, your attorney and the claims administrator may agree on a doctor without using the state system for getting a
QME. The doctor they agree on is called an AME. If they cannot agree, they must ask for a QME.”
Modifier -94 Criteria Not Met -Provider is a QME “selected... from a panel provided by the medical unit.” Modifier -95
Date of Actual Patient Exam: 09/12/2013 as reflected on examination report.
Submitted Service Date on CMS 1500 form: 09/12/2013
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met,Provider States “2 hours.”
(2) 2 or more hours Record Review –Criteria Met,Provider states, “20.5 hours.”
(3) Two or more hours of medical research by the physician; Med. Legal OMFS, “An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical
evidence relied upon” Criteria Not Met –in accordance with §9793 (j): "Medical research" is the investigation of medical issues.
It includes investigating and reading medical and scientific journals and
texts. "Medical research" does not include reading or reading about the Guides for the Evaluation of Permanent Impairment (any
edition), treatment guidelines (including guidelines of the American College of Occupational and Environmental Medicine), the
Labor Code, regulations or publications of the Division of Workers' Compensation (including the Physicians' Guide ), or other
legal materials
.” Provider states “15 min.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.”Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, uponwritten request of the party or parties requesting the report, or if
a bona fide issue of medical causation is discovered in the evaluation.” Request for Causation can be found on Authorization,
Page 2,I ssues 7, addressed on Page 106.
Criteria Met
(7) Apportionment –Criteria Met, pages 107 -110, of PQME Report.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal
evaluation. Criteria Not Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610.
Date of QME 09/12/2013.Criteria Not Met,
Four (4)Complexity Factors Abstracted From QME Report.
ML104 –Attestation pursuant to §9795, Reasonable Level of Fees for Medical-Legal Expenses and CLC §139.3,included in
Examination Report, page 113 of PQME Report (note QME Report reviewed is an unsigned copy).
96100 Psychological testing, per hour.
Time Factors:

229. Face to Face: 2 hours = 8 Units
Record Review: 20 hours 30 min = 82 Units
Research: 15 min = 1Units
Report Prep: 4 hours 15 min = 17 Units
27 Hours = 108 Units
Psychological Testing = 8 hours = 8 Units The table below describes the pertinent claim line information
ML104-94-95 The Claims Administrator down
coded ML 104 to a ML 102 and
reimbursed services $781.25 with
the following rational: “the charge
exceeds the Official Medical Fee
Schedule allowance. The charge
has been adjusted to the scheduled
allowance.” Claims Administrator
also disputing the timeliness of
second bill review.
Provider submitted AME or QME Declaration of Service of Medical–Legal Report dated 7/18/2015 which falls within the
timeframe of the second bill review for this claim.
Communication dated 2/18/15, generated by legal party, identifies the Provider as the requested Panel QME for date of service
2/20/2015.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time
(2) 2 or more hours Record Review
(3) Two or more hours of medical research by the physician;
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors
. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity
factor.”
“Criteria Met : 1.0 hour for history and physical examination time with patient ” and “19.75 hours of record review” (2.0 hours
report
preparation including editing )
(5) “Six or more hours spent on any combination of three complexity factors (1) -(3), which shall count as three complexity
factors.”
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a
bona fide issue of medical causation is discovered in the evaluation .” Criteria Met on page 19 of Provider’s report.

230. (7) Apportionment –Criteria Met.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.Criteria Not Met–QME
Request does not indicate psychiatric o r psychological evaluation .
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610.Criteria Not Met,Date of QME 02/20/2015.
Three (3) Complexity Factors Abstracted From QME Report.
ML104 requires: (2) An evaluation involving prior multiple injuries to the same body part or parts being evaluated, and which
requires three or more of the complexity factors listed under ML 103, including three or more hours of record review by the
physician;
Provider was requested by legal party to discuss patient’s prior injuries to the hip, shoulder and knee.
Provider’s report documents patient complains of right shoulder, right elbow, right hand, lumbar spine , bilateral hips and right
knee pain.
These injuries also stated in Provider’s Review of Medical Records, Physical Examination and Discussion (Causation).
Criteria met for ML104, recommend reimbursement for documented service ML104.
Provider appended modifier -94: Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator. Where
this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.25. Provider was not
requested as the AME but the QME. Increased service value not warranted.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for ML104.
ML104-94-95 The Claims Administrator
reimbursed $4,250.00 with
rationale “reasonable charges on
this case would be 17 hours x 4 =68
units
”
Provider was requested by legal party as a Panel QME for a Psyche evaluation.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time
(2) 2 or more hours Record Review
(3) Two or more hours of medical research by the physician;
 (4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall
count as two complexity factors. Any complexity factor in (1), (2), or(3) used to make this combination shall not also be used as
the third required complexity factor.”Criteria Met: 13 hours for face to face time with patient” and “3 hours of record review (16
hours report preparation)
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met, An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical evidence relied upon page 3 of 4
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .”
CriteriaMet on page 26 of Provider’s report.
(7) Apportionment –Criteria Met on page 27 of Provider’s report.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Met–Communication to injured worker indicates panel QME (Psyche) appointment .
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section

231. 4610. Criteria Not Met.
Four (4) Complexity Factors Abstracted From QME Report.
ML104 requires: (1) An evaluation which requires four or more of the complexity factors listed under ML 103; In a separate
section at the beginning of the report, the physician shall clearly and concisely specify which four or more of the complexity
factors were required for the evaluation, and the circumstances which made these complexity factors applicable to the evaluation.
Provider’s report documents face-to-face time, review of records, Causation, Apportionment and is a psychological evaluation.
Criteria met for ML104, recommend reimbursement for documented service ML104.
Provider appended modifier -94: Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator. Where
this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.25. Provider was not
requested as the AME but the QME. Increased service value not warranted.
Based on the aforementioned documentation and guidelines, additional reimbursement is warranted for ML104
ML104-95
The Claims Administrator down-
coded the billed ML104-95 to
ML103 with the following
explanation: “The documentation
does not support the level of service
billed. Reimbursement was made
for a code that is supported by the
documentation submitted with the
billing.”
Provider disputing reimbursement for ML104-95. Claims Administrator Reimbursed $937.50, Provider submitted $3,125.00.
Provider is seeking full remuneration for services rendered.
The Claims Administrator down-coded the billed ML104-95 to ML103 with the following explanation: “The documentation
does not support the level of service billed. Reimbursement was made for a code that is supported by the documentation
submitted with the billing.”
The Provider, an Orthopedic Specialist, was requested by Legal Parties in the matter of (Injured Worker) v. (Employer/Claims
Administrator) to perform a medical evaluation and render a medical opinion on the Injured Worker. The request is dated
December 27, 2013.
On January 14, 2014 the injured Worker was evaluated by The Provider as requested.
The provided documentation entitled “Qualified Medical Evaluation” was reviewed and compared to the guidelines as dictated
in the Med-Legal OMFS. The OMFS determines the level of a Medical Legal Evaluation by Complexity Factors. The following
complexity factors were abstracted from the QME Report:
1.Four or more hours spent on any combination of two complexity factors (1)-(3), which shall count as two complexity factors.
Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity
factor.
Criteria Met–The Provider Reports: “65 Minutes face to face time,” and “8 hour(s) of record review time.” Addressing the issue
of medical causation upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation
is discovered in the evaluation.

232. Criteria Met-Page 2, request #6, of the request for QME states, “Assuming that abnormalities are present, can it be stated with a
reasonable medical probability that these abnormalities were caused by (Injured Worker’s) August 6, 2012 fall while working.”
Criteria Met-Provider addresses this question on page 26, paragraph 1 of the QME report under the heading, “Causation and
Apportionment.”
3.Addressing the issue of Apportionment under the following circumstances: 1) when determination of this issue requires the
physician to evaluate three or more injuries or pathologies. 2) three or more injuries to the same body system or body region as
delineated in the Table of Contents of Guides to the Evaluation of Permanent Impairment (Fifth Edition). 3) two or more or more
injuries involving two or more body systems or body regions. upon written request of the party
Criteria Not Met; QME, page 26, “Apportionment will be addressed, when I have the opportunity to review...”
OMFS ML 104 Criteria states “4 of More Complexity Factors.” Only 3 Complexity Factors were abstracted from provided
QME Report.
Based on the aforementioned guidelines when compared to the documentation provided, the Provider has met the Criteria for
OMFS ML103: “Complex Comprehensive Medical-Legal Evaluation. Includes evaluations which require three of the complexity
factors.”
OMFS ML 103= $937.50
DETERMINATION OF ISSUE IN DISPUTE: Reimbursement of code ML104 is not warranted based on the aforementioned
guidelines when compared to the documentation
ML104-95 The Claims Administrator denied
service with the following rational:
Provider disputing reimbursement for ML104 services submitted for date of service 01/07/2015.
The Claims Administrator denied service with the following rational: “The Patient cannot be identified as having a claim against

233. “The Patient cannot be identified as
having a claim against this Claims
Administrator.”
this Claims Administrator.”
The Claims Administrator’s Name and address and Claim #listed on State Generated QME Panel Strike Out list is reflected in
the QME report.
QME Panel Strike Out lists are generated by the Claims Administrator.
Communication dated 08/05/2014, indicates Provider is the Panel selected QME;
•01/07/2015 Appointment is indicated; type of Med-Legal appointment and criteria, not indicated.
Aforementioned documentation does not indicate a list of Medical Evaluation Directives or the nature of the Contested Claim.
History of Contested Claim, other than dictated report by Provider, not submitted for IBR.
ML104 requires a “mutual agreement” between the Claims Administrator and the Applicant’s Representative for Extraordinary
Services and a direct request for “causation.”
Documentation reflecting the Claims Administrator and/or Legal Parties’ request for an evaluation involving extraordinary
circumstances (ML104) not received for IBR.
QME Strike Out List addressed to the Applicant’s Attorney does not reflect need for ML104
Extraordinary Circumstances; the directives for this level of exam is not indicated and cannot be
determined, inferred or implied by the Strike Out correspondence.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met, Page 17 of QME Report, the Provider States “2 hours.”
(2) 2 or more hours Record Review –Criteria Not Met, Page 17 of QME Report, Provider states, “2 hours(s) and 30 minutes.”
(3) Two or more hours of medical research by the physician;•Med. Legal OMFS, “An evaluator who specifies complexity factor
(3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon”
Criteria Not Met –in accordance with §9793 (j): "Medical research" is the investigation of medical issues. It includes
investigating and reading medical and scientific journals and texts. "Medical research" does not include reading or reading about
the
Guides for the Evaluation of Permanent Impairment (any edition), treatment guidelines (including guidelines of the American
College of Occupational and Environmental Medicine), the Labor Code, regulations or publications of the Division of Workers'
Compensation (including the Physicians' Guide
), or other legal materials.”
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.” Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met•Page 17 of QME Report, theProvider indicates“6.5
hours”spent producing report, including editing, and case (medical) research.”1.Unable to determine exact time spent on
research.2.Citation page/index not documented. (6) Causation –“Addressing the issue of medical causation, upon written request
of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the evaluation.” Criteria
Not Met as copy of request not received for IBR.•Directive from Claims Administrator/Legal Parties not received. •Unable to
verify discovery of “bona fide issue of medical causation” as past history or directive from Claims Administrator/Legal parties
was not available for review. (7) Apportionment –Criteria Met page 15 of QME report.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met - Provider is a QME Chiropractor.
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the

234. issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Criteria Not Met, Date of QME 01/07/2015.
Three (3) Complexity Factors Abstracted From QME Report.
Criteria not met for ML104, recommend reimbursement for documented service ML103.
ML103 - A basic medical evaluation which involves three complexity factors.
Paid at a flat rate.
All expenses are included except for diagnostic testing.

Based on the aforementioned documentation and guidelines, reimbursement is warranted for ML103
and is not indicated for ML104
ML104-95 The Claims Administrator’s denial
of service in full is based on
accepted body parts.
Provider seeking additional remuneration for ML104-95 services submitted for 05/07/15 date of service.
The Claims Administrator’s denial of service in full is based on accepted body parts.
QME report reviewed by IBR Professional DC. Review indicated some, but not all, of the areas
denied by the Claims Administrator to be relevant to the Med-Legal case.
The QME report does not specify the timing involved in each area of the body; time spent cannot be extrapolated from the body
of the report. Without the documentation of time spent on each accepted, and non-accepted, body part, the total units relevant to
the Med-Legal Evaluation (including report) cannot be determined.
Based on the aforementioned documentation, additional reimbursement cannot be formulated.

235. ML104-95 Claims Administrator reimbursed
$62.50 of the billed total $2625.00
with indication of “the charge
exceeds the Official Medical Fee
Schedule Allowance. The charge
has been adjusted to the scheduled
allowance
Provider seeking remuneration for ML 104.
Claims Administrator reimbursed $62.50 of the billed total $2625.00 with indication of “the charge exceeds the Official
Medical Fee Schedule Allowance. The charge has been adjusted to the scheduled allowance.”
Report submitted documents “2 hours and 30 minutes of face to face time, 1 hour 30 minutes on record review and
6 hours and 30 minutes on report” for a total of 10.5 hours.
Provider states a final EOR was not received from Claims Administrator for their SBR.
Opportunity for Claims Administrator to Dispute Eligibility letter was sent on 10/5/2015. A response from Claims
Administrator was not received for this review.
Based on information reviewed, additional reimbursement of ML 104 is warranted
ML104-95 Claims Administrator down coded
ML 104 to ML 103 with rationale
“Report does not meet 4 or more
complexity factors listed under ML
104 as required by Title 8 CCR
9795”
Provider seeking remuneration for ML 104 performed on 7/1/2015.
Claims Administrator down coded ML 104 to ML 103 with rationale “Report does not meet 4 or more complexity factors listed
under ML 104 as required by Title 8 CCR 9795”
ML103 Complex Comprehensive Medical-Legal Evaluation. Includes evaluations which require three of the complexity factors
set forth below. (1) Two or more hours of face-to-face time by the physician with the injured worker; (2) Two or more hours of
record review by the physician; (3) Two or more hours of medical research by the physician; (4) Four or more hours spent on
any combination of two of the complexity factors (1) - (3), which shall count as two complexity factors. Any complexity factor in
(1), (2), or (3) used to make this combination shall not also be used as the third required complexity factor; (5) Six or more hours
spent on any combination of three complexity factors (1)- (3), which shall count as three complexity factors; (6) Addressing the
issue of medical

236. causation, upon written request of the party or parties requesting the report;(7) Addressing the issue of apportionment
ML 104 (1) An evaluation which requires four or more of the complexity factors listed under ML 103; In a separate section at
the beginning of the report, the physician shall clearly and concisely specify which four or more of the complexity factors were
required for the evaluation, and the circumstances which made these complexity factors applicable to the evaluation. An
evaluator who specifies complexity factor (3) must also provide a list of citations to the sources reviewed, and excerpt or include
copies of medical evidence relied upon.
Report submitted documents: 1.hour face-to-face with applicant 2.16 hours on record review 3. 2 hours on medical research 4.
14 hours on report preparation 5. Apportionment and Causation met A total of 33 hours or 132 units
Abstracted from report included complexity factors (5) which counts as 3 complexity factors , (6) 1 complexity factor and (7) 1
complexity factor. A total of 5 complexity factors were represented in this Medical Legal Report.
Based on information reviewed, additional reimbursement of ML 104 is warranted
ML104-95 Claims Administrator reimbursed
27 units for a total of $1687.50 of
the 99 units billed.
ML 104-95 for date of service 7/3/2015.
Provider was requested as a QME by legal parties.
Claims Administrator reimbursed 27 units for a total of $1687.50 of the 99 units billed.
Pursuant Section 9795: The fee for each evaluation is calculated by multiplying the relative value by $12.50, 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.
Report submitted documents: Face-to-face with patient 6 hours 45 minutes Reviewing records 9 hours Report preparation 9
hours Total time: 24 hours 45 minutes or 99 units
Based on documentation reviewed and guidelines , additional reimbursement of ML 104 is warranted
104 is warranted.
ML104-95 The Claims Administrator The Claims Administrator reimbursed the Provider “$1,625.00” of “$3,812.50, ”indicating “Official Medical Fee Schedule”

237. reimbursed the Provider
“$1,625.00” of “$3,812.50,
”indicating “Official Medical Fee
Schedule” rational.
EOR’s do not indicate ML104level
of services down-coded or denied.
rational.
EOR’s do not indicate ML104level of services down-coded or denied.
Since EOR’s refer to OMFS as reason for reimbursement, the Med-Legal Fee Schedule will be utilized for this review.
Authorization for services not submitted for IBR. However, the Claims Administrators reimbursement and non-
Communicative response to IBR’s Opportunity to Dispute of 10/09/2015 indicates acceptance for ML104 Extraordinary
Circumstances service. This Bill Review will analyze the submitted documentation for the necessary elements required for
ML104 services.
Abstracted data from QME report for date of service 07/06/2015, and submitted documentation, does not support the ML104
Criteria for “Causation” as this element requires a specific request from the Claims Administrator and/or Legal Parties.
The following ML104 Criteria has been met:  Face –to –Face Time: Provider indicates “3 hours.”  Record Review: The
Provider indicates “3 hours.”  Apportionment: Page 11 of the QME report indicates previous “
deferred” status. Page 38 of said report reflects full percentage of Apportionment addressed for date of service 07/06/2015.  A
psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
4 complexity factors abstracted from submitted QME report; Criteria Met for ML104 Services.
Break Down of time as reported on page 1 of the QME report:
3 hours Face-to-Face
3 hours record review
9.25 hours report preparation
oTotal Hours = 15.25
oTotal Units = 61
Noted:Provider separately indicates “5.5 hours” spent on “administration, scoring, and interpretation” of
Psychological testing. This language indicates the ‘5.5 hours ’were not included in the overall time spent preparing the 48 page
QME report. The Total 15.25 Hours indicated for ML104 services does not include the stated 5.5 hours.
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for ML104 services.
ML104-95 Claims Administrator denied
service with rationale “Alternative
services were available and should
have been utilized
Communication from Claims Administrator to the injured worker , and cc’d Provider, dated August 04, 2015 documents injured
workers appointment time and approved location.
CMS 1500 form submitted shows a different address, however, this is the billing address.
Provider’s report documents “Examination Location” and matches that on the authorization form.
Provider’s report also states “This is my Panel Qualified Medical Re-Evaluation of the above -named individual who was seen
at my office in authorized location”

238. Provider documents 1 hour and 30 minutes face-to-face with the applicant, 4.5 hours on record review, 2 hours on medical
research, and 12 hours on report preparation for a total of 20 hours.
Abstracted from Provider’s Qualified Medical Re-Evaluation report: Causation and Apportionment along with Medical
Research in the Appendix : Pursuant 9795–ML 103, (3) Two or more hours of medical research by the physician An evaluator
who specifies complexity factor (3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of
medical evidence.
Based on aforementioned documentation, reimbursement of ML 104 is warranted
ML104-95 Claims Administrator down coded
ML 104 to a ML 103and
reimbursed Services $937.50 with
the following rational: “the charge
exceeds the Official Medical Fee
Schedule allowance. The charge has
been adjusted to the scheduled
allowance
.
Communication dated June 3, 2015, generated by legal party, identifies the Provider as the requested Panel QME for date of
service 7/13/2015.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time
(2) 2 or more hours Record Review
(3) Two or more hours of medical research by the physician;
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall
count as two complexity factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as
the third required complexity factor.”
(5) “Six or more hours spent on any combination of three complexity factors (1) -(3), which shall count as three complexity
factors.” Criteria Met : 2.0 hour for history and physical examination time with patient;
12 hours of record review ; and 1 hour of medical research (6.0 hours report preparation, writing and editing). Appendix B at the
end of Provider ’s report documents medical research Provider reviewed.
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .” Criteria
Met on page 43 of Provider’s report.
(7) Apportionment –Criteria Not Met.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met–QME Request does not indicate psychiatric or psychological evaluation.
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013,addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610. Criteria Not Met.
Three (4) Complexity Factors Abstracted From QME Report.
ML104 requires: (1) An evaluation which requires four or more of the complexity factors listed under ML 103; In a separate
section at the beginning of the report, the physician shall clearly and concisely specify which four or more of the complexity

239. factors were required for the evaluation, and the circumstances which made these complexity factors applicable to the evaluation.
An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources reviewed, and excerpt or
include copies of medical evidence relied upon.
Criteria met for ML104.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for ML104.
ML104-95 Claims Administrator down coded
ML 104 to a ML 103
And reimbursed services
$843.75 with the following rational:
“documentation doesn’t support the
level of service
.
Communication dated July 20, 2015, generated by legal party, identifies the Provider as the requested
Panel QME for date of service 8/04/2015.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time
(2) 2 or more hours Record Review
(3) Two or more hours of medical research by the physician;
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall
count as two complexity factors . Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used
as the third required complexity factor.” Criteria Met : 1.5 hours for history and physical examination time with patient and 6
hours of record review (6 hour s report preparation)
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.”
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation .” Criteria Met on page 6 of Provider’s report.
 (7) Apportionment –Criteria Met.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met–QME Request does not indicate psychiatric or psychological evaluation.
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610.Criteria Not Met.
Four (4) Complexity Factors Abstracted From QME Report.
ML104 requires: (1) An evaluation which requires four or more of the complexity factors listed under ML 103; In a separate
section at the beginning of the report, the physician shall clearly and concisely specify which four or more of the complexity

240. factors were required for the evaluation, and the circumstances which made these complexity factors applicable to the evaluation.
Criteria met for ML104.
Based on the aforementioned documentation and guidelines, reimbursement is warranted for ML104
ML104-95 The Claims Administrator denied
ML104 indicating “Charge exceeds
the Official medical Fee Schedule
allowance.”
Provider seeking remuneration for ML104 services submitted for date of service 07/20/2015.
The Claims Administrator denied ML104 indicating “Charge exceeds the Official medical Fee Schedule allowance.”
Communication from legal party to Provider dated June 16, 2015 requesting Panel Qualified Medical Evaluation appointment
7/20/2015 on above named injured worker.
Evaluation Documentation compared to ML104 OMFS “4 or more complexity factors” requirement:
(1) 2 or more hours Face-to-Face time –Criteria Met,“2 hours face-to face with applicant.”
(2) 2 or more hours Record Review –Criteria Met, “6 hours .”
(3) Two or more hours of medical research by the physician;
•Med. Legal OMFS, “An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources
reviewed, and excerpt or include copies of medical evidence relied upon” Criteria Not Met –(3) Two or more hours of medical
research by the physician; Med. Legal OMFS, “An evaluator who specifies complexity factor (3) must also provide a list of
citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon” Criteria Not Met –in accordance
with §9793 (j): "Medical research" is the investigation of medical issues. It includes investigating and reading medical and
scientific journals and texts. "Medical research" does not include reading or reading about the Guides for the Evaluation of
Permanent Impairment (any edition), treatment guidelines (including guidelines of the American College of Occupational and
Environmental Medicine), the Labor
Code, regulations or publications of the Division of Workers' Compensation (including the Physicians' Guide), or other legal
materials.”
Due to aforementioned guidelines, Medical Research will not be considered a factor in this Medical Legal review.
(4)“Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity
factors . Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required
complexity factor.”Criteria Met
(5) “Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity
factors.” Criteria Not Met
(6) Causation –“Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or
if a bona fide issue of medical causation is discovered in the evaluation.” Criteria Met page 20 of QME Report.
(7) Apportionment –Criteria Met page 20 of QME report.
(8) For dates of injury before December 31, 2012 where the evaluation occurs on or before June 30, 2013, addressing the issue
of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances; Criteria Not Met.
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
Criteria Not Met
(10) For dates of injury before December 31, 2012 where the evaluation that occurs on or before June 30, 2013, addressing the
issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section
4610.Criteria Not Met, Date of QME 07/20/2015.
Four (4 ) Complexity Factors Abstracted From QME Report. Five Complexity Factors = ML104.
Opportunity for Claims Administrator to Dispute Eligibility sent on 2/10/2016. Response from Claims Administrator not
received for this review.
Based on the aforementioned documentation and guidelines, ML104 reimbursement is warranted

241. ML104-95 Claims Administrator reimbursed
$7125.00 indicating “20 hours
billed for records review is a bit
excessive”
and only reimbursed Provider for
14.5 hours.
§ 9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal
Evaluations and Medical-Legal Testimony.(b) The fee for each evaluation is calculated by multiplying the relative value by
$12.50, 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.
Provider ’ s report submitted documents:
30 minutes face-to-face
20 hours on record review
2 hours on medical research
12 hours on report preparation
A total of 34 hours and 30 minutes,or 138 units,were spent on the ML 104 submitted to Claims Administrator.
Based on guidelines and documentation reviewed, additional reimbursement for ML 104 is warranted.
ML104-95-25 Claims Administrator denied
service originally. A third EOR
submitted by Claims Administrator
Provider seeking remuneration of ML 104 on date of service 02/07/2015
Provider was requested to perform a Qualified Medical Evaluation by the Legal Parties.
Provider’s report documents: 10 hours of record review, 90 minutes of face to face time, 5 hours of report preparation time for a

242. after the dispute had been filed,
shows ML 104 processed with a
payment to be made to Provider in
the amount of $4125.00
total of 16.5 hours or 66 units.
Claims Administrator denied service originally. A third EOR submitted by Claims Administrator after the
dispute had been filed, shows ML 104 processed with a payment to be made to Provider in the amount of $4125.00.
If payment has been received in the amount of $4125.00, then the Claims Administrator is only responsible for the IBR fee of
$195.00 to be paid to Provider
ML106 EOR indicate services denied to
“insufficient information” required
to adjudicate claim.
Provider seeking remuneration for ML106 services submitted for date of service 10/28/2015.
EOR indicate services denied to “insufficient information” required to adjudicate claim.
Opportunity to Dispute Eligibility communicated with the Claims Administrator on 05/17/2016; response received not yet
received.
ML106 Supplemental Medical-Legal Evaluation. The physician shall be reimbursed at the rate of RV 5, 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. Fees will not be allowed under this section for
supplemental reports following the physician's review of (A) 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 the initial report or (B) the results of laboratory
or diagnostic tests which were ordered by the physician as part of the initial evaluation.
$63.50/15 min or $240.00/hr
Communication from the Claims Administrator, dated 09/29/2015, verifies the Provider agreed to “reexamine” the Claimant in
the capacity of QME. Page 2, Paragraph 3, the acknowledgement direct the Provider to “prepare a detailed written report...”
The submitted report does not fit the Criteria of a “supplemental” report as the QME was asked to ‘
reexamine’ the patient and to generate a new report (not to expound on the initial examination), and to determine causation of a
“new worker s compensation claim for an injury on 8/1/2015.”
Based on the directives generated by the Claims Administrator, Med -Legal Examination involving extraordinary circumstances,
was requested.
Document entitled “Fee Justification” indicates the following regarding Record Review, Medical Research, and Report
Preparation:
10/28/2015 5 hours
10/29/2015 6.2 hours
§9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal
Evaluations and Medical-Legal Testimony (j) "Medical research
" is the investigation of medical issues. It includes investigating and reading medical and scientific journals and texts. "Medical
research" does not include reading or reading about the Guides for the Evaluation of Permanent Impairment (any edition),

243. treatment guidelines (including guidelines of the American College of Occupational and Environmental Medicine), the Labor
Code, regulations or publications of the Division of Workers' Compensation (including the Physicians' Guide), or other legal
materials.
ML103/ML104: An evaluator who specifies complexity factor (3)must also provide a list of citations to the sources reviewed,
and excerpt or include copies of medical evidence relied upon.
The Exact hours spent on medical research cannot be extrapolated from the submitted ‘Fee Justification,’
and a list of citations pertaining to references research was not submitted for IBR.
Fee Justification indicating Time spent on Record Review and Medical Research reflect accumulative time. These Complexity
Factors for ML103/ML104 -Record Review and Medical Research, require separate accountability in terms of time.
The criteria for ML103/ML104 services has not been met.
ML101 Follow-up Medical-Legal Evaluation criteria is not met as the Claims Administrator indicates on page 1, paragraph 4 of
the QME acknowledgment letter, “The purpose of this examination is to determine the cause of his August 1, 2015 claimed
injury to the low back,” which is after the initial evaluation of
a separate claim relating to the QME evaluation on 07/15/2015 for “low back and abdomen.”
The documentation clearly indicates a Med-Legal evaluation was requested and subsequently performed. However, the
necessary criteria has not been provided for Med-Legal evaluations 1, 3, 4 & 6. Submitted documentation supports ML102
services.
ML102 - Basic Comprehensive Medical-Legal Evaluation. Includes all comprehensive medical-legal evaluations other than
those included under ML 103 or ML 104.
Based on the aforementioned documentation, reimbursement is not indicated for ML106, recommend reimbursement as ML102
ML106 Communication from the Claims
Administrator dated November 2,
2015 requesting a reexamine of the
injured worker as a Panel Qualified
Medical Examiner with a list of
directives to submit in his report
was submitted for this review.
Provider seeking remuneration of ML 106 for date of service 12/09/2015.
Communication from the Claims Administrator dated November 2, 2015 requesting a reexamine of the injured worker as a
Panel Qualified Medical Examiner with a list of directives to submit in his report was submitted for this review.
The submitted request does not mention any other medical records that would be sent later for his review and response.
QME report for reexamine dated November 5, 2015 submitted for this review.
§ 9795 ML 106: Fees for supplemental medical-legal evaluations. The physician shall be reimbursed at the rate of RV 5, 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. Fees will not be allowed under this section for supplemental reports following the physician's review of
(A) 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 the initial report or (B) the results of laboratory or diagnostic tests which were ordered by the
physician as part of the initial evaluation.
A request/authorization from the Claims Administrator for additional record review with report was not identified in this review.
Based on documentation and guidelines, reimbursement for ML 106 is not warranted

244. ML106-94 Claims Administrator reimbursed
Provider $2,968.75 and then re-
cooped funds for service.
Provider is seeking remuneration for ML 106-94 service on 04/20/2015.
Claims Administrator reimbursed Provider $2,968.75 and then re-cooped funds for service.
Provider was requested to review additional medical records of a patient that he evaluated one month prior to this date of service
04/20/2015 and provide a supplemental report of the records and of any changes to Provider’s previous opinion.
ML106: Supplemental medical-legal evaluations: Fees will not be allowed under this section for supplemental reports following
the physician's review of (A) 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 the initial report or (B) the results of laboratory or diagnostic tests which were
ordered by the physician as part of the initial evaluation.
§ 9793 (m) "Supplemental medical-legal evaluation" means an evaluation which (A) does not involve an examination of the
patient, (B) is based on the physician's review of records, test results or other medically relevant information which was not
available to the physician at the time of the initial examination, (C) results in the preparation of a narrative medical report
prepared and attested to in accordance with Section 4628 of the Labor Code, any applicable procedures promulgated under
Section 139.2 of the Labor Code, and the requirements of Section 10606 and (D) is performed by a qualified medical evaluator,
agreed medical evaluator, or primary treating physician following the evaluator's completion of a comprehensive medical-legal
evaluation.
Original report of the AME evaluation and CMS 1500 form billing ML 104-94 on date of service 03/09.2015 was submitted for
review.
Supplemental Report documenting “I spent 9.5 hours reviewing records and preparing and proofreading this report” and CMS
1500 form billing ML 106-94 was also submitted for review.
Opportunity for Claims Administrator to Dispute Eligibility was sent on 9/29/2015. A response from Claims Administrator was
not received for this review.
Based on information reviewed, reimbursement of ML 106-94 is warranted.
Provider was also charged a fee for the returned check in the amount of $65.00 which Claims Administrator is responsible to
reimburse Provider.

245. ML106-95 Provider seeking remuneration for ML106-95 services performed on 04/02/2015.
The Claims Administrator denied services based on need for “authorization.”
Communication from the Claims Administrator’s Legal Parties, dated 03/06/2015, request the following from the Provider:
“Defendant requests that you review your prior reports, as well as the applicant’s deposition testimony, and provide the parties
with your opinion as to whether there was more than one period of continuous trauma.”
8 C.C.R. §§ 9793, 9795 Medical -Legal Fee Schedule Proposed Regulations (2) The report is obtained at the request of a party
or parties, the administrative director, or the appeals board for the purpose of proving or disproving a contested claim and
addresses the disputed medical fact or facts specified by the party, or parties or other person who requested the comprehensive
medical-legal evaluation report. Nothing in this paragraph shall be construed to prohibit a physician from addressing additional
related medical issues.
§9793(l) "Supplemental medical-legal evaluation" means an evaluation which (A) does not involve an examination of the
patient, (B) is based on the physician's review of records, test results or other medically relevant information which was not
available to the physician at the time of the initial examination, (C) results in the preparation of a narrative medical report
prepared and attested to in accordance with Section 4628 of the Labor Code, any applicable procedures promulgated under
Section 139.2 of the Labor Code, and the requirements of
Section 10606 and (D) is performed by a qualified medical evaluator, agreed medical evaluator, or primary treating physician
following the evaluator's completion of a comprehensive medical-legal evaluation.
ML106: Supplemental medical -legal evaluations: Fees will not be allowed under this section for supplemental reports following
the physician's review of (A) 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 the initial report or (B) the results of laboratory or diagnostic tests which were
ordered by the physician as part of the initial evaluation.
The aforementioned 03/06/2015 was requested by Legal Representation of the Claims Administrator for purposes of “proving or
disproving” a claim.
It is noted the Claims Administrator’s Address presented on the request is not the address indicated on the CMS 1500 or the
EOR. However, the Claims Administrator’s name and contact person is identical to that of the
request.
Supplemental Report reflects “1 hour”
ML106-95 = ML 106 RV 5 Per 15 Min., $62.50/15 min or $250/hr .
Based on the aforementioned documentation and guidelines, reimbursement is warranted for ML106-95

246. ML106-95 Claims Administrator reimbursed
ML 106 and a separate 99080 which
was denied payment.
Provider seeking remuneration for ML 106
Provider was requested to review additional records and provide a supplemental report.
Provider’s report documents “billing: Report Writing: 4 hours 15 minutes, Records Review: 3 hours 10 minutes, Total Hours: 7
hours 25 minutes”
ML 106 -Fees for supplemental medical-legal evaluations. The physician shall be reimbursed at the rate of RV 5, 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. Fees will not be allowed under this section for supplemental reports following the physician's review of (A)
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 the initial report or (B) the results of laboratory or diagnostic tests which were ordered by the
physician as part of the initial evaluation.
The fee for each evaluation is calculated by multiplying the relative value by $12.50, 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
Provider’s Invoice to Claims Administrator shows ML 106-95: Time Collating & Reviewing Medical Records 17
units and Report Preparation & Medical Research 13 units. Total balance $1,875.00.
Claims Administrator reimbursed ML 106 and a separate 99080 which was denied payment.
As total units are to be applied to the level of the Medical Legal report, additional reimbursement of ML 106 is warranted.
ML106-96 The Claims Administrator denied
reimbursement pending
Provider seeking remuneration for ML106 services performed on 08/01/2015.
The Claims Administrator denied reimbursement pending “authorization.”

247. “authorization.” Original QME Authorization Reviewed.
Provider indicates ML106 based on unavailable records at time of initial exam.
SBR Request, dated 08/26/2015, indicates the Provider is seeking $1,406.25 for ML106 services requiring “four hours and thirty
minutes.”
ML106 Definition: Fees for supplemental medical-legal evaluations. The physician shall be reimbursed at the rate of RV 5, 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. Fees will not be allowed under this section for supplemental reports following the physician's
review of (A) 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 the initial report or (B) the
results of laboratory or diagnostic tests which were ordered by the physician as part of the initial evaluation.
ML106 Report reflects discussion regarding new documentation beginning on page 88 of the PQME report.
Units of “four hours and thirty minutes”= 18 Units
Based on the aforementioned documentation and guidelines, reimbursement for ML106 x 18 units is warranted.
NCD's 38779-0082-
09, 63275
-9913-09, 51552
-1285-08
Claims Administrator provided the
following explanation for denial:
“non FDA approved agent,
therefore is considered non
reimbursable.”
Provider is dissatisfied with the denial of a compounded drug product containing NCD's 38779-0082-09, 63275-9913-09, 51552-
1285-08for date of service 05/20/2015.
Provider is a compound pharmacy.
Per Labor Code Section 5307.1(e) (2) compounded drug products are to be billed by the pharmacy or dispensing physician at the
ingredient level by National Drug Code (NDC) and quantity. The ingredient-level reimbursement shall be equal to 100 percent of
the reimbursement allowed by the MEDI-CAL payment system and payment shall be based on the sum of the allowable fee for
each ingredient plus a dispensing fee allowed by MEDI-CAL. If dispensed aby a physician, the maximum reimbursement shall
not exceed 300 percent of documented paid costs, but no more than twenty dollars above documented paid costs.
For any pharmacy goods dispensed by a physician not subject to the above, the maximum reimbursement to a physician for
pharmacy goods dispensed by the physician shall not exceed any of the following: the allowed amount in the Official Medical
Fee Schedule, one hundred twenty percent of the documented paid cost to the physician, or one hundred percent of the
documented paid cost to the physician plus two hundred fifty dollars.
Claims Administrator provided the following explanation for denial: “non FDA approved agent, therefore is considered non
reimbursable.”
Authorization dated May 14, 2015 for requested procedure Flurbiprofen/Lidocaine Cream 20%/5% signed by Claims
Administrator states “medically necessary”

248. Documentation included a prescription for Flurbiprofen/Lidocaine 20%/5% cream 180gm.
Claim form documented the following: Dispensed Qty.180; Unit of Measure GM; Lidocaine HCLPowder NDC
38779-0082-09Ingredient Qty.9; Flurbiprofen Powder NDC 63275-9913-09, Qty.36; Pentravan Plus Cream base NDC 51552-
1285-08, Qty.135.
Reimbursement calculated on the Workers' compensation pharmacy fee schedule - Compound prescription Calculator
Based on the NCD's 38779-0082-09, 63275-9913-09, 51552-1285-08 and billed quantity of 180 grams reimbursement of is
warranted.
Claims Administrator submitted payment to Provider in the amount $1739.24 after this dispute was filed. Claims Administrator
requested this dispute be terminated. The Provider is the only one who may terminate an IBR once filed and a notice to terminate
case 15-0001993 was not submitted.
As Claims Administrator has already reimbursed Provider for services on 5/20/2015, Claims Administrator is only responsible
for the IBR fee of $195.00 to be paid to Provider.
Telephone call
services (99371-
99373)
must be medically necessary or contribute to the overall care of the injured worker. Telephone calls must have supporting
documentation in the medical record with a brief description of the conversation no
ted. The CPT 99373 code is to be used for complex or lengthy telephone calls. It would involve a lengthy, emergent counseling
session with an anxious or distraught patient or detailed or prolonged discussion with family members regarding a seriously ill
patient. Basic telephone call services reported by CPT 99371 and 99372 typically include: test and/or laboratory results; to clarify
or alter previous instructions; to integrate new information from other health professionals into the medical treatment plan;
WC002 and 99215 Provider is dissatisfied with denial of codes 99215 and WC002 for date of service 05/07/2015.
Claims Administrator denied codes indicating on the Explanation of Review “Procedure/services are disallowed as they are not
authorized”
Letter dated January 17, 2014 documents injured worker’s selection of Provider as the Primary Treating Physician.
Office visits with the Primary Treating Physician do not require prior authorization.
PR-2 submitted documents follow up visit for the patient’s persistent pain in the lower back.
Based on information reviewed, reimbursement of 99215 and WC002 is warranted

249. WC002 and 99215 Claims Administrator denied codes
indicating on the Explanation of
Review “Provider not authorized to
bill for proc/svc”
Provider is dissatisfied with denial of codes WC002 and 99215
Claims Administrator denied codes indicating on the Explanation of Review “Provider not authorized to bill for proc/svc”
Letter dated September 12, 2014 from injured worker requesting Provider as the primary treating physician
And signed by injured worker was identified in this review.
Letter dated 11/19/2014 from Claims Administrator to Provider shows confirmation as Primary Treating Physician.
PR-2 submitted documents services provided on date of service 3/24/2015.
Based on information reviewed and in accordance with §9781 Employee's Request for Change of Physician, reimbursement of
99215 and WC002 is warranted.
WC004 The Claims Administrator denied
the service with the following
rational: “This report does not fall
under the guidelines of separately
reimbursable reports.”
Provider seeking remuneration for WC004 Reports services charged on 05/06/2014.
The Claims Administrator denied the service with the following rational: “This report does not fall under the guidelines of
separately reimbursable reports.”
WC004: Primary Treating Physician’s Permanent and Stationary Report (Form PR-4).

250. Exhaustive search for Authorization from Claims Administrator regarding WC004 Services could not be located for the IBR
process.
Evaluation documentation May 6, 2014 indicates Injured Worker was referred to Provider for
a “Permanent and Stationary” evaluation.
Evaluation documentation page 8 of 9 indicates, “Prior to evaluation, it was explained to the examinee that this appointment was
for the purposes of evaluation only-not for care, treatment or consultation
-and therefore, no doctor-patient relationship would result.”
§9785. Reporting Duties of the Primary Treating Physician.1) The "primary treating physician" is the physician who is primarily
responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering
or prescribing treatment and has monitored the effect of the treatment thereafter. The primary treating physician is the physician
selected by the employer or the employee pursuant to Article 2 (commencing with section 4600) of Chapter 2 of Part 2 of
Division 4 of
applicable to a Health Care Organization certified under section 4600.5 of the Labor Code.(2) A
"secondary physician" is any physician other than the primary treating physician who examines or provides treatment to the
employee, but is not primarily responsible for continuing management of the care of the employee.
Based on the aforementioned documentation and guidelines, the Provider is a ‘secondary physician.’
Reimbursement for WC004 is not warranted for secondary physician status.
WC004 and 99215
-17
The Claims Administrator denied
services as not authorized.
Provider seeking remuneration for 99215-17 Evaluation and Management Permanent and Stationary service and WC004 Primary
Treating Physician Permanent and Stationary Report performed on 04/02/2015.
The Claims Administrator denied services as not authorized.
May 6, 2014 communication from Legal Parties identifies the Provider as the “Primary Treating Physician” for Injured Worker.
Primary Treating Physician Office Visits for Accepted Body Parts do not require Prior Authorization.
California Specific Modifier –17 = Primary Treating Physician Permanent and Stationary Report.
The determination of an Evaluation and Management service for Established Patients require two of three key components in
the following areas:
1)History: Chief Complaint, History of Present Illness, Review of Systems (Inventory of Body Systems), Past Family and Social
History.
2)Examination: Problem Focused, Expanded Problem Focused, Detailed Comprehensive “(General multi-system examination, or
complete examination of a single organ system or other symptomatic related body area(s) or organ

251. system(s).”
3)Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a
management option, which is determined by considering the following factors:
a.The number of possible diagnoses and/or the number of management options that must be considered;
b.The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed,
and analyzed; and
c.The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s
presenting problem(s), the diagnostic procedure(s), and/or the possible management options.
Evaluation and Management Levels/Elements (History / Exam / Medical Decision
Making), Established Patient:
99212 = Problem Focused / Problem Focused / Straight Forward
99213 = Expanded Problem Focused / Expanded Problem Focused/ Low Complexity
99214 = Detailed History / Detailed Exam / Moderate Complexity
99215= Comprehensive; HPI= 4 + elements or status of 3 chronic conditions, ROS= 10 + Systems, PFSH 2 History Areas;
Comprehensive Physical Exam-two from EACH of nine organ systems; High Complexity
Medical Decision Making, 2 of 3 in the following areas: 4Problem Points or Management Options, 4 Data (record review, test
discussion/ordering etc.,) & High Level of Risk.
Time: In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or
family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility),
time is considered the key or controlling factor to qualify for a particular level of E/M services. The total length of time of the
encounter (faced-to-face) should be documented and the record should describe the counseling and/or activities to coordinate
care.
Abstracted information from Primary Treating Physician Permanent and Stationary Report revealed 99215 level of service.
WC004 Primary Treating Permanent and Stationary Report verified. WC004: $38.68 for first page $23.80 each additional page.
Maximum of seven pages absent mutual agreement ($181.48).
Based on the aforementioned documentation and guidelines, reimbursement is warranted for 99215-17 & WC004.
WC004 x 8 and 99499 Provider seeking remuneration for 99499 Unlisted Evaluating and management Services Prolonged Services and WC004 Primary

252. x 8 Treating Physician's Permanent and Stationary Report performed on 08/07/2014.
CPT 99499 Services denied by the Claims Administrator as “included in the value of another service performed on the same
day.”
Authorization for aforementioned services and relating fees signed by Claims Administrator on 5/22/14 as “Approved.”
Labor Code §4611 states: (a) When a contracting agent sells, leases, or transfers a health provider’s contract to a payor, the
rights and obligations of the Provider shall be governed by the underlying contract between the health care provider and
contracting agent.
Pursuant to LC § 5307.11–“the medical fee schedule shall not apply to the contracted reimbursement rates.” California State
Assembly Bill 1177 amended the Labor Code effective January 1, 2002 to add §5307.11:
LC § 5307.11 states:A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code,
and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule
adopted and revised pursuant to Section 5307.1. When a health care provider or health facility
licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for
reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health
facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to
the contracted reimbursement rates.
Provider’s PR-4 submitted documents “WC004 reflecting 8 pages used” and “2 hours for records review”
Complete Contractual Agreement not submitted for review.
Opportunity to Dispute Eligibility communicated to Claims Administrator on 2/03/2016; response not yet received.
Authorization dated 5/22/14 is contractual in nature; reimbursement is warranted pursuant to LC § 5307.11 for 99499 and
WC004
WC007 The Claims Administrator denied
service in full stating, “a charge was
made or a separate procedure that
does not meet the criteria for
separate payment. See Physician ’s
Fee Schedule Gen.”
Communication from Claims Administrator, dated March 12 , 2014b, to referring Provider reflects status as “Panel Qualified
Medical Examiner,” requested by Claims Administrator to perform Med-Legal Evaluation and “this letter constitutes your
authority to perform all tests which you believe are necessary.”
OMFS Physician Fee Regulations 1/1/2014: § 9789. 12.12 Consultation Services Coding , (b) Consultation reports are bundled
into the underlying evaluation and management visit 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
Submitted referral from AME (referring Provider) to Provider indicates the following
stamped request:
EMG/NCV and Neurodiagnostic testing and Consultation Report of Bilateral Upper Ext.

253. WC007 - $38.68 for first page $23.80 each additional page . Maximum of six pages absent mutual agreement ($157.68)
Based on the aforementioned, reimbursement is warranted for WC007-30
WC007-30 The Claims Administrator denied
service with rationale “The visit or
service billed occurred within the
global surgical period and is not
separately reimbursable.”
Provider seeking remuneration for WC007–30 Consultation Reports, performed on 03/19/2015.
The Claims Administrator denied service with rationale “The visit or service billed occurred within the global surgical period
and is not separately reimbursable.”
§9789.14. Reimbursement for Reports, Duplicate Reports, Chart Notes. The following treatment reports are separately
reimbursable.(5) Consultation Reports that are separately reimbursable. The following reports are separately reimbursable.
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.
Request for “EMG/NCV and Neurodiagnostic Testing and Consultation Report of Bilateral Upper Extremity,”
Dated 03/02/2015, from Referring AME to Provider.
WC007 -$38.68 for first page -maximum of six pages absent mutual agreement ($157.68)
Based on the aforementioned documentation and guidelines, reimbursement is warranted for WC007-30