(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:
  (1) the examination;
  (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) Treating doctors must only bill and be reimbursed for an MMI and 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 treating doctor determines that MMI has not been reached, the treating doctor must bill, and the insurance carrier must reimburse, the MMI evaluation portion of the examination in accordance with subsections (c)(1) and (c)(2) of this section.
  (2) If the treating doctor determines MMI has been reached and there is no permanent impairment because the injury was sufficiently minor, an IR evaluation is not warranted and the treating doctor must bill, and the insurance carrier must reimburse, only the MMI evaluation portion of the examination in accordance with subsections (c)(1) and (c)(2) of this section.
  (3) If the treating doctor determines MMI has been reached and an IR evaluation is performed, the treating doctor must bill, and the insurance carrier must reimburse, both the MMI evaluation and the IR evaluation portions of the examination in accordance with subsection (c) of this section.
  (4) If the treating doctor is not authorized to assign an IR, the treating doctor may refer the injured employee to an authorized doctor for the examination and certification of MMI and IR. The referred doctor must bill under §134.260 of this chapter.
(c) The following applies for billing and reimbursement of an MMI or IR evaluation by a treating doctor.
  (1) CPT code. The treating doctor must bill using CPT code 99455 with the appropriate modifier. Modifiers "V3," "V4," or "V5" must be added to CPT code 99455 to correspond with the last digit of the applicable office visit.
  (2) MMI. MMI evaluations must be reimbursed based on the applicable established patient office visit level associated with the examination under §134.203 of this chapter.
  (3) IR. For IR examinations, the treating 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 treating doctor may bill for a maximum of three body areas.
      (i) Musculoskeletal body areas are:
        (I) spine and pelvis;
        (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 treating doctor must bill, and the insurance carrier must reimburse, for each non-musculoskeletal body area examined.
      (i) Non-musculoskeletal body areas are defined as follows:
        (I) body systems;
        (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 treating 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 treating doctor outlined in subsection (c) of this section.
(e) The treating doctor is required to review the certification of MMI and assignment of IR performed by another doctor, as stated in the Labor Code and Chapter 130 of this title. The treating doctor must bill using CPT code 99455 with modifier "VR" to indicate a review of the report only, and the insurance carrier must reimburse $64 adjusted per §134.210(b)(4).

Source Note: The provisions of this §134.250 adopted to be effective July 7, 2016, 41 TexReg 4839; amended to be effective June 1, 2024, 49 TexReg 1489