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Learning Objectives
Describe the Medical-Legal base rate codes (ML201, ML202, ML203)
Discuss each of the modifiers and when they can be used
Why do I have to know this?
The changes to QME CE will take effect for re-appointment after April 01, 2026. The QME CE requirements will go from 12 hours to 16 hours and certain types of course will be required. The 16 hours of instruction in continuing education shall include:
(1) A minimum of 4 hours of instruction in disability impairment rating;
(2) A minimum of 3 hours of instruction in medical-legal report writing;
(3) A minimum of 2 hour of instruction in anti-bias training which meets the qualifications outlined in Section 11(h);
(4) A minimum of 2 hours in of instruction consisting of a review of workers’ compensation case law;
(5) A minimum of 1 hour of instruction in proper application of the medical-legal fee schedule or in QME adherence to regulatory clerical requirements; and
(6) The remaining 4 hours may include credit earned in a number of other ways
This course is designed to satisfy number five above – the proper application of the medical-legal fee schedule.
QME BILLING MADE SIMPLE
California’s Qualified Medical Evaluators (QMEs) are paid according to a specific, state-regulated structure — the Medical-Legal Fee Schedule (MLFS). The new Fee Schedule has been in effect since April 1, 2021. Beginning with QME renewals after April 15, 2026, QMEs will be required to have a one-hour CE course in ML billing.
OVERVIEW OF THE MEDICAL-LEGAL FEE SCHEDULE
The MLFS is governed by CCR §9795 and §9795.1, effective April 1, 2021. It establishes: (1) Flat fees for specific medical-legal services (ML200–ML203) and (2) Add-on fees for excess records, extended evaluations, and interpreter coordination — if properly documented
PRIMAY MEDICAL-LEGAL SERVICE CODES
ML200 Missed Appointment
Missed appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation, $503.75
ML201 Comprehensive Medical-Legal Evaluation
All comprehensive medical-legal evaluations that do not qualify as follow-up or supplemental medical-legal evaluations, $2,015
ML202: Follow-up Medical-Legal Evaluation
Follow-up medical-legal evaluation by a physician which occurs within eighteen (18) months of the date on which a prior comprehensive medical-legal evaluation was performed by the same physician, $1,316.25
ML203: Supplemental Medical-Legal Evaluation
Services for writing a report after receiving a request for a supplemental report from a party to the action, or receiving records that were not available at the time of the initial or follow-up comprehensive medical-legal evaluation, $650.00
ML204: Medical-Legal Testimony
All itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time, $455/hour ($113.75 per each 15-minute increment)
ML205: Sub Rosa Recording Review
Time spent reviewing sub rosa recordings. $325/hour ($81.25 per each 15-minute increment)
MLPRR: Record Review
Used to identify charges for review of records in excess of pages included in medical-legal numerical billing codes, $3.00 per page
FEE SCHEDULE DETAILED BREAKDOWN
The following provides more information about each of the codes.
ML200 Missed Appointment
- The injured worker does not show up for the evaluation
- The interpreter does not show up for the evaluation which makes it impossible to go forward with the exam
- The injured worker leaves the evaluation before the completion of the evaluation
- The injured worker is more than 30 minutes late for the appointment and the QME is unable to continue with the scheduled QME appointment
- The appointment has been canceled within six business days of the scheduled appointment date.
- If the physician produces a record review report within 30 days of the date of the missed appointment the physician shall be reimbursed at the rate of $3.00 per page for any records reviewed in excess of 200 pages.
- Any pages reviewed for this record review report will be excluded from the page count for reimbursement when the face-to-face or supplemental evaluation takes place.
ML201 Comprehensive Medical-Legal Evaluation
- Includes all comprehensive medical- legal evaluations that do not qualify as
- Follow-up or Supplemental Medical-Legal Evaluations
- The fee includes review of 200 pages of records
- Review of records in excess of 200 pages shall be reimbursed at the rate of $3.00 per page
ML202: Follow-up Medical-Legal Evaluation
- Follow-up medical-legal evaluation by a physician which occurs within eighteen (18) months of the date on which a prior comprehensive medical-legal evaluation was performed by the same physician,
- The fee includes review of 200 pages of records that were not reviewed
- as part of the initial comprehensive medical-legal evaluation
- or as part of any intervening supplemental medical-legal evaluations.
- Review of records in excess of 200 pages that were not reviewed as part of the initial comprehensive medical-legal evaluation or as part of any intervening supplemental medical-legal evaluations shall be reimbursed at the rate of $3.00 per page
ML203: Supplemental Medical-Legal Evaluation
- Services for writing a supplemental report after receiving a request for a supplemental report from a party to the action, or receiving records that were not available at the time of the initial or follow-up comprehensive medical-legal evaluation
- 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 a comprehensive medical- legal report or a follow-up medical-legal report; or
- Addressing an issue that was requested by a party to the action to be addressed in a prior comprehensive medical-legal evaluation, a prior follow- up medical-legal evaluation, or a prior supplemental medical-legal evaluation.
- The fee includes review of 50 pages of records
- Review of records in excess of 50 pages that were received as part of the request for the supplemental report shall be reimbursed at the rate of $3.00 per page
ML204: Medical-Legal Testimony
- The physician shall be reimbursed $455/hour or his or her usual and customary fee, whichever is less
- Time is rounded to the nearest quarter hour, spent by the physician
- 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 two hours for a deposition
- If a deposition is canceled fewer than eight (8) calendar days before the scheduled deposition date, the physician shall be paid a minimum of one hour for the scheduled deposition
ML205: Sub Rosa Recording Review
- The physician shall be reimbursed at the rate of $325.00/hour or his or her usual and customary hourly fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician for time spent reviewing sub rosa recordings.
- The fee for reviewing sub rosa recordings may be allowed in addition to any fee for any single report written by the physician as a result of the review of the sub rosa recordings.
- If the sub rosa recordings are received by a physician prior to the issuance of a pending report related to a medical-legal evaluation, the physician may not also bill a supplemental report fee in connection with the review of the sub rosa material.
MLPRR - RECORD REVIEW
ML200, 201 & 202
The base fee includes review of up to 200 pages. If more than 200 pages are reviewed, then one can charge $3.00 per page over 200 pages. This pertains to records that were not previously reviewed as part of the initial comprehensive medical-legal evaluation or as part of any intervening supplemental medical-legal evaluations. There is no time tracking required relative to this charge for records review; however, the records reviewed must be documented in your report
ML203 (Supplemental Reports)
The base fee includes up to 50 pages of records. If more than than 50 pages are reviewed (after the initial evaluation), then you can bill $3.00 per page over 50 pages. This applies only to new records received after the ML201/ML202. The review of records must be documented in the report.
- Example: If you receive 200 new pages post-evaluation, you may bill 150 excess pages × $3.00 = $450.00
- Record Review Details
- There are several rules that must be followed in terms of the records review for them to be payable. These include the following:
- Record review must be conducted by the physician
- Records are documents sent to the physician in connection with a medical-legal evaluation or request for report.
- The documents may consist of medical records, legal transcripts, medical test results, and/or other relevant documents.
- A page is defined as an 8 ½ by 11 single-sided document, chart or paper, whether in physical or electronic form.
- Multiple condensed pages or documents displayed on a single page shall be charged as separate pages.
- Documents sent to the physician for record review must be accompanied by a declaration under penalty of perjury that the provider of the documents has complied with the provisions of Labor Code section 4062.3 before providing the documents to the physician.
- The declaration must also contain an attestation as to the total page count of the documents provided.
- A physician may not bill for review of documents that are not provided with this accompanying required declaration from the document provider.
- Any documents or records that are sent to the physician without the required declaration and attestation shall not be considered available to the physician or received by the physician for purposes of any regulatory or statutory duty of the physician regarding records and report writing.
- When billing for a record review, MLPRR, the physician shall include in the report a verification under penalty of perjury of the total number of pages of records reviewed by the physician as part of the medical-legal evaluation and preparation of the report.
NON-BILLABLE ITEMS (ACROSS ALL CODES)
Per §9795.1(d), the following are not reimbursable:
- Staff time, clerical time, or administrative overhead
- Photocopying, faxing, or mailing costs
- Office expenses (rent, phone, EHR systems)
- Time preparing invoices
MEDICAL-LEGAL MODIFIERS
The services described by Procedure Codes ML-201 through ML-203 may be modified under the circumstances described in this subdivision. The modifiers shall not be applicable to per page charges for record review in any of the Procedure Codes ML-201 through ML-203. The modifying circumstances shall 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:
-93 (Interpreter)
- 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.
- Where this modifier is applicable, the value for the procedure is modified by multiplying the normal value by 1.1. This modifier shall only be applicable to ML- 201 and ML-202.
-94 (AME)
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.35.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.45.
-95 (Panel QME)
- 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.
-96 (Psych QME)
- Evaluation performed by a Psychiatrist or Psychologist when a psychiatric or psychological evaluation is the primary focus of the medical-legal evaluation.
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 2.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.10.
- If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.35.
- If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 2.45.
-97 (Toxicology)
- Evaluation performed by a physician who is board certified in Toxicology, a physician who is certified as a Qualified Medical Evaluator in the specialty of Internal Medicine or a physician who is board certified in Internal Medicine, when a Toxicology evaluation is the primary focus of the medical-legal evaluation.
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.50.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.60.
- If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.85.
- If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.95.
-98 (Oncology)
- Evaluation performed by a physician who is board certified in Medical Oncology, a physician who is certified as a Qualified Medical Evaluator in the specialty of Internal Medicine or a physician who is board certified in Internal Medicine, when an Oncology evaluation is the primary focus of the medical-legal evaluation.
- Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.50.
- If modifier -93 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.60.
- If modifier -94 is also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.85.
- If both modifier -93 and -94 are also applicable for an ML-201 or ML-202, then the value of the procedure is modified by multiplying the normal value by 1.95.
EXAMPLES
If you reviewed 675 pages for an ML201, how much can you charge beyond the base rate?
The ML201 base rate includes 200 pages of records review and $3.00 per page after that. Therefore, you may bill 475 pages × $3.00 = $1,425.00 additional.
You are doing a supplemental report (ML203) and you recieve 400 page of records, 200 of which you already reviewed as part of the intial evaluation. How much can you charge?
The base fee (ML203) includes up to 50 pages of records. If more than than 50 pages are reviewed (after the initial evaluation), then you can bill $3.00 per page over 50 pages. This applies only to new records received after the ML201/ML202. In this case, you have recieved 200 new pages and 50 pages is included in the base fee. Therefore, you can charge an additional $450 (150 X $3.00).
In the following scernarios, how much can you charge: An intial evaluation (ML201) with 1427 pages of records:
Medical Panel QME (PQME) - (ML201-95). This would be the base rate of $2015 and an additional $3681 (1427 - 200 or 1227 x $3.00 = 3681) for a total of $5696.00
Psych QME (ML201-95-96). This would be the base rate ($2015) multipled by the 2.0 modifer or $4030. Then there the additional $3681 for a total of $7711.00
Psych QME with interperter (ML201-95-96-93). This would be the base rate ($2015) multipled by the 2.1 or $4231.50. Then there is the additional $3681 for a total of $7912.50
Psych AME with interperter (ML201-94-96-93). This would be the base rate ($2015) multipled by the 2.45 modifier (AME with interpreter) or $4936.75. Then there is the additional $3681 for a total of $8617.75.
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