Section 134.260 - Maximum Medical Improvement Evaluations and Impairment Rating Examinations by Referred Doctors(a) The total maximum allowable reimbursement (MAR) for a maximum medical improvement (MMI) or impairment rating (IR) examination is equal to the MMI evaluation reimbursement plus the reimbursement for the body area or areas evaluated for the assignment of an IR. The MMI or IR examination must include: (2) consultation with the injured employee;(3) review of the records and films;(4) the preparation and submission of reports (including the narrative report and responding to the need for further clarification, explanation, or reconsideration), calculation tables, figures, and worksheets; and(5) tests used to assign the IR, as outlined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), as stated in the Labor Code and Chapter 130 of this title.(b) Referred doctors must only bill and be reimbursed for an MMI or IR examination if they are an authorized doctor in accordance with the Labor Code and Chapter 130 and § 180.23 of this title. (1) If the referred doctor determines that MMI has not been reached, the referred doctor must bill, and the insurance carrier must reimburse, the MMI evaluation portion of the examination in accordance with subsection (c)(1) and (2) of this section. The referred doctor must add modifier "NM."(2) If the referred doctor determines that MMI has been reached and there is no permanent impairment because the injury was sufficiently minor and IR evaluation is not warranted, the referred doctor must bill, and the insurance carrier must reimburse, only the MMI evaluation portion of the examination in accordance with subsection (c)(1) and (2) of this section.(3) If the referred doctor determines MMI has been reached and an IR evaluation is performed, the referred doctor must bill, and the insurance carrier must reimburse, both the MMI evaluation and the IR examination portions of the examination in accordance with subsection (c) of this section.(c) The following applies for billing and reimbursement of an MMI or IR evaluation by a referred doctor.(1) CPT code. The referred doctor must bill using CPT code 99456 with the appropriate modifier.(2) MMI. MMI evaluations will be reimbursed at $449 adjusted per §134.210(b)(4).(3) IR. For IR examinations, the referred doctor must bill, and the insurance carrier must reimburse, the components of the IR evaluation. Indicate the number of body areas rated in the units column of the billing form. (A) For musculoskeletal body areas, the referred doctor may bill for a maximum of three body areas. (i) Musculoskeletal body areas are: (II) upper extremities and hands; and(III) lower extremities (including feet).(ii) For musculoskeletal body areas:(I) the reimbursement for the first musculoskeletal body area is $385 adjusted per §134.210(b)(4); and(II) the reimbursement for each additional musculoskeletal body area is $192 adjusted per §134.210(b)(4).(B) For non-musculoskeletal body areas, the referred doctor must bill, and the insurance carrier must reimburse, for each non-musculoskeletal body area examined.(i) Non-musculoskeletal body areas are:(II) body structures (including skin); and(III) mental and behavioral disorders.(ii) For a complete list of body system and body structure non-musculoskeletal body areas, refer to the appropriate AMA Guides.(iii) The reimbursement for the assignment of an IR in a non-musculoskeletal body area is $192 adjusted per §134.210(b)(4).(d) If the examination for the determination of MMI or the assignment of IR requires testing that is not outlined in the AMA Guides, the referred doctor must bill, and the insurance carrier must reimburse, the appropriate testing CPT code or codes according to the applicable fee guideline in addition to the fees for the examination by the referred doctor outlined in subsection (c) of this section.28 Tex. Admin. Code § 134.260
Adopted by Texas Register, Volume 49, Number 10, March 8, 2024, TexReg 1496, eff. 6/1/2024