Includes evaluations which require three of the following complexity factors: The physician shall, in a separate section at the beginning of the report, clearly and concisely specify three or more of the complex factors listed below which were required for the evaluation and the circumstances which made these complexity factors applicable to the evaluation.

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 be counted as two complexity factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not be used as the third required complexity factor ;
5. six or more hours spent on any combination of the 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, or if a bona fide issue of medical causation is discovered in the evaluation;
7. addressing the issue of apportionment, upon written request of the party or parties requesting the report, or if a bona fide issue of apportionment is discovered in the evaluation;
8. addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biological substances;
9. a psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.

Legal Evaluation Involving Extraordinary Circumstances; Medical-Legal Testimony; Supplemental Medical-Legal Evaluations. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary hourly fee, whichever is less, for each hour or portion thereof spent by the physician for any of the following:

1. Fees for comprehensive medical-legal evaluations where there are extraordinary circumstances relating to the medical condition being evaluated. Evaluations which typically involve extraordinary circumstances include the following examples as well as evaluations of comparable complexity: a. An evaluation which requires four or more of the complexity factors listed under ML103; b. An evaluation involving prior multiple injuries to the same body part or parts being evaluated, or a complex issue of medical causation, and which requires three or more of the complexity factors listed under ML103, including three or more hours of record review by the physician; c. An agreed medical evaluation which is obtained after each party has obtained its own evaluation, which involves complex issues of medical causation or apportionment; d. An agreed medical evaluation for which the physician and the parties agree, prior to the evaluation, that the evaluation involves extraordinary circumstances. When billing under this code for extraordinary circumstances, the physician shall include in his report (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: reviewing the records, face-to-face time with the injured worker, preparing the report and if applicable, any other activities.
2. Fees for medical-legal testimony. The physician shall be entitled to fees for all itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time. The physician shall be paid a minimum of one hour for a scheduled deposition.
3. Fees for supplemental medical-legal evaluations. Fees will not be allowed for 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 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.

(d) The services described by Procedure Codes ML101 through ML104 may be modified under the circumstances described in this subdivision. When applicable, the modifying circumstances should be identified by the addition of the appropriate modifier code, which is reported by a two-digit number placed after the usual procedure number separated by a hyphen. The modifiers available are the following:
-92 Performed by a primary treating physician. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by .80, except where services are performed under ML 104.
-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 circumstances and the increased time required for the examination as a result. Where this modifier is applicable, the value for the procedure is modified by multiplying the normal value by 1.1. This modifier shall not be applicable to ML 104.
-94 Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator. Where this modifier by multiplying the normal value by .25. If modifier -93 is also applicable, the value of the procedure is modified by multiplying the normal value by 1.35.
-95 Evaluation performed by a panel selected Qualified Medical Evaluator for an uncontested claim. This modifier should be added to the code reflecting the appropriate level of evaluation performed. This modifier is added solely for identification purposes, and does not change the normal value of the service.
-96 Modifier for medical-legal testimony. This modifier is added solely for identification purposes, and does not change the normal value of the service.
-97 Modifier for supplemental medical-legal evaluations. This modifier is added solely for identification purposes, and does not change the normal value of the service.
(e) Request for duplicate reports shall be in writing. Duplicate reports shall be separately reimbursable. Where the payer requests an additional copy of the report, the payer shall reimburse for the duplicate report at $10.00 for up to the first 15 pages. Pages in excess of 15 pages shall be reimbursed at $0.25 per page.
(f) This section shall apply to medical-legal evaluation reports where the examination occurs on or after the effective date of this section. Amendments to this section shall apply to medical-legal evaluation reports where the examination to which the report refers occurs on or after the effective date of the amendments and to medical-legal testimony where such testimony occurs on or after the effective date of the amendments. The 1999 amendments to this section shall apply to medical-legal evaluation reports where the medical examination to which the report refers occurs on or after April1, 1999, and to medical-legal testimony on or after April 1, 1999.

MEDICAL TREATMENT BILLING

For Sacramento, San Francisco, Clovis and Santa Rosa. Please contact Sandy Hedges in our Sacramento office (916) 455-3300.

For Castroville, Salinas and San Jose. Please contact Yadira and Kerry in our Castroville office at (831) 633-1831

PERSONAL INJURY CASES

For Evaluations:

**$ 500.00 deposit for Orthopedic, Neurological, Cardiology, Internal Medicine. There is a $1,000.00 deposit for Psychiatric cases.

Personal Injury Cases**

Most Personal Injury cases Range from $ 500.00-$ 750.00. **$1,000.00 deposit for Psychological Personal Injury Cases** Psychological cases Range from $1,460.00 and increase. The balance will be liened.

For Depositions and Trials:

$ 400.00 per hour for Depositions, plus any additional expenses, such as travel.
$3,000.00 for ½ day, plus any additional expenses, such as travel.
$5,000.00 for full day, plus any additional expenses, such as travel.

SOCIAL SECURITY

$400.00 for Basic Social Security Cases (Orthopedic, Neurology, etc.)
$400.00 for Complex Social Security Cases (Psychological)

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