Chapter 13: Independent Medical Exams (IME)
Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims
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Effective July 1, 2012 |
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Table of contents
Payment policy:
Independent medical exams (IMEs)
More info:
Related topics
Definitions
Body areas:
For IMEs, the following body areas are recognized:
- Head, including the face,
- Neck,
- Chest, including breasts and axilla,
- Abdomen,
- Genitalia, groin, buttock,
- Back, and
- Each extremity.
Note: Each extremity is counted once per extremity examined, when determining standard or complex codes. For example, in a case of bilateral carpal tunnel syndrome, if both right and left extremities are examined, 2 body areas would be counted.
Bundled:
A bundled procedure code isn’t payable separately because its value is accounted for and included in the payment for other services. Bundled codes are identified in the fee schedules.
Pharmacy and DME providers can bill HCPCS codes listed as bundled in the fee schedules. This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.
Link: For the legal definition of “bundled,” see WAC 296-20-01002 .
By report:
A code listed in the fee schedule as “BR” doesn’t have an established fee because the service is too unusual, variable, or new. When billing for the code, the provider must provide a report that defines or describes the services or procedures. The insurer will determine an appropriate fee based on the report.
Link: For more information, see WAC 296-20-01002 .
Local code modifier mentioned in this chapter:
X-rays and laboratory services in conjunction with an IME
When X-rays, laboratory, and other diagnostic tests are provided with an exam, identity the service(s) by adding the modifier – 7N to the usual procedure number.
Link: Procedure codes are listed in the L&I Professional Services Fee Schedules, Radiology and Laboratory Sections, available at http://feeschedules.Lni.wa.gov .
Organ systems:
For IMEs, the following organ systems are recognized:
- Eyes,
- Ears, nose, mouth, and throat,
- Cardiovascular,
- Gastrointestinal,
- Genitourinary,
- Respiratory,
- Musculoskeletal,
- Skin,
- Neurologic,
- Psychiatric, and
- Hematologic/ Lymphatic/ Immunologic.
Payment policy: Independent medical exams (IMEs)
Who must perform an IME to qualify for payment
Only doctors with an IME provider account number can bill IME codes.
Links: To obtain an application:
- Go to www.Lni.wa.gov/forms/pdf/245046af.pdf , or
For more information on becoming an approved IME provider or to perform impairment ratings:
- See the Medical Examiners’ Handbook (F252-001-000 ) at www.Lni.wa.gov/IPUB/252-001-000.pdf , or
- Go to www.Lni.wa.gov/ClaimsIns/Providers/Becoming/IME/default.asp.
To receive email updates on IMEs, subscribe to the ListServ at www.Lni.wa.gov/Main/Listservs/IME.asp .
Services that can be billed
IME unique billing codes
| Local billing code | Description and notes | Maximum fee |
| 1104M | IME, addendum report. Requested and authorized by claim manager. Addendum report for information that isn’t requested in original assignment, which necessitates review of records. Isn’t to be used for review of job analysis or review of diagnostic testing or study results ordered by the examiner. |
$114.31 |
| 1105M | IME Physical Capacities Estimate. Must be requested by the insurer. Bill under lead examiner’s provider account number for multi-examiner exams. |
$30.51 |
| 1108M | IME, standard exam – 1-3 body areas or organ systems Use this code if there are only 1-3 body areas or organ systems that need to be examined for sufficient evaluation of the accepted condition(s). An appropriate exam and reporting of an injury or condition limited to 1-3 body areas or organ systems. Records are reviewed and the report includes a detailed chronology of the injury or condition as described in the Medical Examiners’ Handbook . Physical exam is directed only toward the affected body areas or organ systems. Diagnostic tests needed are ordered and interpreted. Impairment rating is performed if requested. The IME report must contain the required elements noted in the Medical Examiners’ Handbook. The report conclusions address how the examined body areas or organ systems relate to the accepted or contended work related injury(s) or condition(s). Includes review of up to 2 job analyses. L&I expects that these exams will typically involve at least 30 minutes of face-to-face time with the patient. This code can be used by:
|
$497.51 |
| 1109M | IME, complex exam – 4 or more body areas or organ systems Use this code if there are 4 or more body areas or organ systems that need to be examined for sufficient evaluation of the accepted condition(s). An appropriate exam and reporting of an injury or condition of 4 or more body areas or organ systems. Records are reviewed and the report includes a detailed chronology of the injury or condition, as described in the Medical Examiners’ Handbook . Physical exam is directed only toward the affected body areas or organ systems. Diagnostic tests needed are ordered and interpreted. Impairment rating is performed if requested. The report conclusions address how the examined body areas or organ systems relate to the accepted or contended work related injury(s) or condition(s). The IME report must contain the required elements noted in the Medical Examiners’ Handbook. Includes review of up to 2 job analyses. L&I expects that these exams will typically involve at least 45 minutes of face-to-face time with the patient. This code can be used by:
|
$621.87 |
| 1111M | IME, no-show fee, per examiner. Bill only if appointment time cannot be filled Isn’t payable for no-shows of IME related services (for example, neuropsychological evaluations, performance based PCEs). For more information, see WAC 296-20-010 . |
$211.71 |
| 1134M | IME late cancellation fee, per examiner Bill only if appointment time cannot be filled and cancellation is within 3 business days of exam. (Business days are Monday thru Friday.) Isn’t payable for no-shows of IME related services (for example, neuropsychological evaluations). |
$211.71 |
| 1112M | IME, additional examiner for IME Use where input from more than 1 examiner is combined into 1 report. Includes:
|
$443.02 |
| 1118M | IME by psychiatrist
|
$900.30 |
| 1120M | IME, no-show fee, psychiatrist Bill only if appointment time cannot be filled Isn’t payable for no-shows of IME related services (for example, neuropsychological evaluations). For more information, see WAC 296-20-010 . |
$328.16 |
| 1135M | IME late cancellation fee, psychiatrist Bill only if appointment time cannot be filled and cancellation is within 3 business daysof exam. (Business days are Monday thru Friday.) Isn’t payable for no-shows of IME related services (for example, neuropsychological evaluations). |
$328.16 |
| 1122M | Impairment rating by an approved pain program Program must be approved by insurer Impairment rating must be requested by the insurer. Must be performed by a doctor currently licensed in medicine and surgery (including osteopathic and podiatric physicians), dentistry, or L&I approved chiropractic examiners. (For more information, see WAC 296-20-2010 ). The rating report must include at least the following elements as described in the Medical Examiners’ Handbook :
|
$497.51 |
| 1123M | IME, communication issues Exam was unusually difficult due to expressive problems, such as a stutter, aphasia or need for an interpreter in a case that required an extensive history as described in the report. If interpreter needed, verify and record name of interpreter in report. Bill once per examiner per exam. Isn’t payable with a no-show fee (1111M or 1120M). |
$200.07 |
| 1124M | IME, other, by report Requires preauthorization and prepay review:
|
By report |
| 1125M | Physician travel per mile Allowed when roundtrip exceeds 14 miles. Code usage is limited to extremely rare circumstances. Requires preauthorization and prepay review:
|
$4.90 |
| 1128M | Occupational disease report. Must be requested by insurer. Examples of conditions which L&I considers occupational diseases are:
This is a detailed assessment of work-relatedness, with the exact content presented in the Medical Examiners’ Handbook . A doctor may bill this code only once for each patient. |
$185.03 |
| 1129M | IME, extensive file review by examiner Units of service are based on the number of hardcopy pages reviewed by the IME examiner on microfiche, paper, Claim and Account Center, or other medium. Review of the first 550 hardcopy pages is included in the base exam fee (1108M, 1109M, 1118M, or 1130M). Bill for each additional page reviewed beyond the first 550 hardcopy pages. Isn’t payable with 1111M or 1120M. Only the following document categories will be paid for unless the authorizing letter requests a review of all documents:
Bill for unique documents not duplicates. Payment won’t be made for review of duplicate documents. Note: To be eligible for payment, a detailed chronology of the injury or condition must be included in the report as defined by the Medical Examiners’ Handbook . |
$1.01 |
| 1130M | IME, terminated exam Bill for exam ended prior to completion. Requires file review, partial exam and report (including reasons for early termination of exam). |
$354.40 |
| 1131M | IME, out-of-state exam | By report |
| 1132M | Document printing of electronic medical records per page. Payable only once per IME referral. Charges must be based on printing the following electronic records unless the authorizing letter requests a review of all documents:
|
$0.07 per printed page |
| 1133M | IME, document processing fee. Payable only once per IME referral. Note: This fee includes the preparation of documents for examiner review. The preparation of documents includes duplicate document removal. |
$59.29 |
| 1139M | IME, no show fee for missed neuropsychological testing. Must be scheduled or approved by department or self-insurer as part of an independent medical examination. (For more information, see WAC 296-20-010 (5).) This code is payable only once per independent medical examination assignment. Must notify department or self-insurer of no-show as soon as possible. Bill only if appointment cannot be filled. |
$889.62 |
| 1140M | IME, no show fee for missed PCE. Must be scheduled or approved by department or self-insurer as part of an independent medical examination. (For more information, see WAC 296-20-010 (5).) This code is payable only once per independent medical examination assignment. Must notify department or self-insurer of no-show as soon as possible. Bill only if appointment cannot be filled. |
$284.57 |
| Modifier -7N |
X-rays and laboratory services in conjunction with an IME. When X-rays, laboratory, and other diagnostic tests are provided with an exam, identify the service(s) by adding the modifier – 7N to the usual procedure number. Link: Procedure codes are listed in the L&I Professional Services Fee Schedules, Radiology and Laboratory Sections, available at http://feeschedules.Lni.wa.gov . |
n/a |
Note: See definition of bundled in “Definitions” at the beginning of this chapter.
Multiple claim codes
| Local billing code | Description and notes | Maximum fee |
| 1136M | IME, two claims included in evaluation. Medical examination includes second claim to be evaluated by the medical examiner. This code is used in addition to the primary IME exam code (1108M, 1109M, 1112M, 1118M, or 1130M) only. This shouldn’t be reported as a stand-alone code. Bill once per examiner. Note: This must be pre-authorized by state fund claim manager or self-insured employer/third party administrator. |
$100.80 |
| 1137M | IME, Three claims included in evaluation. Medical examination includes second and third claims to be evaluated by the medical examiner. This code is used in addition to the primary IME exam code (1108M, 1109M, 1112M, 1118M, or 1130M) only. This shouldn’t be reported as a stand-alone code. Bill once per examiner. Note: This must be pre-authorized by state fund claim manager or self-insured employer/third party administrator. |
$201.60 |
| 1138M | IME, four or more claims included in evaluation. Medical examination includes second, third, and four or more claims to be evaluated by the medical examiner. This code is used in addition to the primary IME exam code (1108M, 1109M, 1112M, 1118M, or 1130M) only. This shouldn’t be reported as a stand-alone code. Bill once per examiner. Note: This must be pre-authorized by state fund claim manager or self-insured employer/third party administrator. |
$302.40 |
Requirements for billing
Billing State Fund (L&I) for in state IMEs
For IMEs performed in Washington State, examiners need one IME provider account number for each payee they wish to designate.
An IME examiner who isn’t working through any IME firms will need just one IME number, which will also serve as their payee number.
How IME firms must bill for IMEs conducted in Washington state
The chart below shows which provider account number and/or National Provider Identifier (NPI) to use in 24J of the CMS 1500 form (F245-127-000 ) based on the IME service provided.
Note: The NPI must be registered with the department.
| Use only the IME examiner’s provider account number/NPI for these CPT® or local billing codes: |
Use only the IME firm provider account number/NPI for these codes: |
The following codes may be billed by the IME examiner, the IME firm, or by the performing provider. |
|
| 1028M | 1118M | 1132M | 1124M |
| 1038M | 1120M | 1133M | 90801 |
| 1048M | 1123M | 96101, 96102 | |
| 1066M | 1125M | 96118, 96119 | |
| 1104M 1105M |
1128M | X-ray, diagnostic laboratory tests in conjunction with IME (use modifier -7N). |
|
| 1108M | 1129M | 1045M | |
| 1109M | 1130M | ||
| 1111M 1112M 1134M 1135M 1136M 1137M 1138M |
99441-99443 | ||
Note: On the CMS-1500 (F245-127-000 ), IME firms may use their own provider account number (box 33b) and/or NPI (box 33a) as the “payee” although it isn’t required if the same provider account number/NPI is in box 24J.
Billing for out of state IMEs
A separate provider account number is required for IMEs conducted outside of Washington State.
IME examiners must meet L&I’s criteria for approved examiners.
IME examiners must be approved by L&I.
Link: To obtain the procedures and an IME provider application, go to www.Lni.wa.gov/ClaimsIns/Providers/Becoming/IME/default.asp.
When you submit your application include a copy of the doctor’s license for the state where the exam will be conducted and current curriculum vitae (CV).
Firms won’t be required to put the examiner provider account number on State Fund bills.
Bills for out of state IMEs must contain the IME firm’s provider account number in box 33b of the CMS-1500 bill form (F245-127-000 ).
Bill your usual and customary fees.
Use billing code 1131M for all services, except the CPT® codes for neuropsychological evaluation and testing.
- Combine all 1131M charges into one line item on your bill. Also use 1131M for activities occurring after the IME, such as addendums.
- L&I and self-insurers will reimburse 1131M by report.
Note: See definition of by report in “Definitions” at the beginning of this chapter.
Standard and complex coding
The exam should be sufficient to achieve the purpose and reason the exam was requested.
Choose the code based on the number of body areas or organ systems that need to be examined to fully evaluate the accepted condition(s) or the condition(s) contended as work related.
Be sure the report documents the relationship of the areas examined to the accepted or contended conditions.
The definitions of body areas and organ systems from the Current Procedural Terminology (CPT®) book must be used to distinguish between standard and complex IMEs.
Note: See definitions of body areas and organ systems in “Definitions” at the beginning of this chapter.
Payment limits
Limit on total scheduled exams per day
L&I has placed a limit of 12 independent medical examinations scheduled per examiner per day. This limit is inclusive of IMEs scheduled for State Fund and self-insured claims. The applicable codes include:
- 1108M IME, standard exam – 1-3 body areas or organ systems,
- 1109M IME, complex exam – 4 or more body areas or organ systems,
- 1111M IME, no-show fee, per examiner,
- 1112M IME, additional examiner for IME,
- 1118M IME by psychiatrist,
- 1120M IME, no-show fee, psychiatrist,
- 1122M Impairment rating by an approved pain program,
- 1130M IME, terminated exam,
- 1131M IME, out-of-state exam,
- 1134M, Late cancellation fee,
- 1135M, Late cancellation fee, psychiatrist,
- 1136M, IME, two claims included in evaluation,
- 1137M, IME, three claims included in evaluation, and
- 1138M, IME four or more claims included in evaluation.
Links: Related topics
| If you’re looking for more information about… | Then go here: |
| Administrative rules for IME no shows |
Washington Administrative Code (WAC) 296-20-010(5): http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-010 |
| Administrative rules for impairment ratings |
WAC 296-20-2010: http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-2010 |
| Application to become an IME provider (State Fund) |
L&I’s website: www.Lni.wa.gov/forms/pdf/245046af.pdf |
| Becoming an L&I provider | L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp |
| Billing instructions and forms | Chapter 2: Information for All Providers |
| Fee schedules for all healthcare professional services |
L&I’s website: http://feeschedules.Lni.wa.gov |
| Performing impairment ratings | Medical Examiner’s Handbook: www.Lni.wa.gov/IPUB/252-001-000.pdf |
| Receiving email updates on IMEs | Subscribe to L&I’s ListServ: www.Lni.wa.gov/Main/Listservs/IME.asp |
Need more help? Call L&I’s Provider Hotline at 1-800-848-0811.
CPT® codes and descriptions only are © 2011 American Medical Association
