Another Odd QME Report Payment Question (California) (Califo

[appliedpsych]

Here’s another odd QME (psychology) payment issue.

IC pays most of QME bill, which was properly billed under WC 9795, using ML-codes for all services. Oddly, first time I have seen an IC try this in 15 years, they carve out the ML 104 services for psychological testing, saying that this is a diagnostic service that they are obliged to pay for psychological testing only under the OMFS, CPT Code 96100, citing WC 9794 to wit:

(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.

Of course they seem to gloss over the fact that in the cover letter, the Claims Adjustor did authorize any psychological testing I deemed necessary, and I did of course list subjective and objective factors.

I think they are mixing apples and oranges, trying to quote a section that applies to treatment services (9794), instead of the appropriate QME services (9795).

If what they say is is true, why has no IC in 15 years tried the same gimmick? Am I missing something?

Any comments on the validity or invalidity of the IC opinion appreciated.

[rider001]

You billed the psych testing as an ML?

[appliedpsych]

I don't bill for the time of the applicant to fill out the testing. I bill for the time to score, analyze, synthesize, and correlate testing results into the formulation of the report.

[rider001]

I think the issue is $250/hr for ML and $99.91/hr for 96100. Bill them seperately for the testing or put on lien.

96100
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

[cmunday]

Dear Applied

I'm amazed you've not been corrected on this previously. There is no question in my mind that psychological testing is to be billed per the OMFS and not as med-legal time. This is no different from a neurologist billing for his/her time to do an EMG or NCVs at med-legal rates - would not be allowed. I do know some people who have done this and candidly acknowledge that they know it's not correct but if they don't get corrected.....I disagree. The only times I have charged med-legal rates for testing is when I had to travel. Recently went to a nursing facility to see a severely disabled person - but I got an agreement before-the-fact that all of my time would be reimbursed at med-legal rates (ironically in this case the person was not able to do any testing).

I'd be very interested if anyone disagrees and if they can cite some authority to back up their position.

Claude Munday

[appliedpsych]

I understand about the administration, scoring and interpretation of psychchological testing. That's the simple part, including software scoring so that an interpretation report is available. Those tasks encompasses 96100. To me, that is where 96100 ends.

That is not what I am referring to.

I am referring to then integrating those test findings into the formulation of the QME report. For example, studying my testing results and comparing that to testing that has been conducted by others as provided in the review documents, comparing pain ratings on the Pain Patient Profile to actual pain information documentation available in the records. Comparing personality characteristics identified by the testing to medical provider review documents that may help to explain why one applicant has much more problems adapting to an orthopedic injury and than some others, and how those figure into disability ratings, apportionment issues, etc.

[rider001]

But thats not where the code ends.
96100
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

I am not saying this is right but one could argue interpreting the test results is comparing them to the prior testing etc.

I am curious as to how much detail you went into delineating how your time was spent?

[appliedpsych]

I am not saying this is right but one could argue interpreting the test results is comparing them to the prior testing etc.

No way that would be true. The scoring, interpretation and reporting apply strictly to each test separately.

For example when billing non-industrial medical insurance plans, many companies assign each psychological test a certain time figure to account for the scoring and write-up of the results. For example, tests such as the MMPI2 and MCMI3 are allocated by most general insurance companies as allocated for one hour to score, interpret and report.

Just as in QME evals, the time for the individual being administered a test to complete the test is so variable that the general understanding is that the person completes the testing on their own, and that administration time itself is not billed. Some slow readers for example may take 2 to 3 hours to wade through an MMPI2, with its over 500 questions.

The interpretation and report applies separately to each test, and does not extend to complex medical-legal comparative use and synthesis - - - which is why they become much more complicated in a medical-legal setting, and why this complex use becomes part and parcel to the formulation of the QME report, thus requiring billing for that portion.

Psychological evaluations are recognized under 9795, at the ML 103 and ML 104 levels, as having special complexities. It is specifically noted in that section that the QME can bill with "... 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 and, if applicable, any other activities.

[appliedpsych]

I'd be very interested if anyone disagrees and if they can cite some authority to back up their position. Claude Munday

Dr. Munday:

In regards to this issue, I know that on the Work Comp Central Flowchart, available on this website, there is something that you and perhaps readers can comment on. The box labeled "Official Medical Fee Schedule" has, in part, the following statement:

"The Official Medical Fee Schedule applies to all medical services except ... medical-legal expenses under LC 4621 and medical expenses under Reg 9795".

Doesn't this support the idea that the OMFS does not apply to psychological testing performed for QME Evaluations ? ? ?

[appliedpsych]

I'd be very interested if anyone disagrees and if they can cite some authority to back up their position. Claude Munday

RE-READING CLOSELY THE STRANGELEY WRITTEN LEGALESE OF 9795, I think this supports my opinion. I'll break it up to make it easier to read the language.

Section 9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony.

(a) The schedule of fees set forth in this section shall be prima facie evidence of the reasonableness of fees charged for medical-legal evaluation reports, and fees for medicallegal testimony. 8 C.C.R. §§ 9793, 9795 Medical-Legal Fee Schedule Regulations May, 2006

Reports by treating or consulting physicians --- OTHER THAN --- comprehensive, follow-up or supplemental medical-legal evaluations, ... shall be subject to the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1 ---- rather than to the fee schedule set forth in this section.

In other words, --- comprehensive, follow-up or supplemental medical-legal evaluations ---- ARE subject to the SPECIAL RULES OF 9795 ---- AND THUS ARE NOT subject to the OMFS.

[comprehensive, follow-up or supplemental medical-legal evaluations are the type of evaluations that are conducted by a Panel QME's or AME's
who ARE NEITHER treating or consulting physicans. Thus, payment is PER 9795 AND NOT PER OMFS FOR ANY AND ALL SERVICES by Panel QME's or AME's.

What's your take on that ?

This would indicate that the WC Flow Chart Item I mentioned above is correct and in harmony with the Regs. Care to chime in Davidd ? ? ?