Site Alert

WorkerWeb and ProviderWeb online claim filing are down for maintenance until Monday, October 27th. We apologize for any inconvenience.

Chapter 13: Independent Medical Exams (IME)


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



Go Back Return to Billing & Payment Policies


Go Back Return to Fee Schedule Lookup

Effective July 1, 2013

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

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. 

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:

–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 .

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.

Back to top

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:

For more information on becoming an approved IME provider or to perform impairment ratings:

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.
$115.22
1105M IME Physical Capacities Estimate form (F242-387-000)
Must be requested by the insurer.
Bill under lead examiner’s provider account number for multi-examiner exams.
$30.75
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:
  • Single examiners,
  • Leads on multiexaminer exams where findings from other examiners are combined into 1 report, and
  • Examiners on multiexaminer exams who perform separate file review, exam and standalone reports.
Note: Additional examiners who aren’t leads: use 1112M.
$501.49
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:
  • Single examiners,
  • Leads on multiexaminer exams where findings from other examiners are combined into 1 report, and
  • Examiners on multiexaminer exams who perform separate file review, exam and standalone reports.
Note: Additional examiners who are not leads: use 1112M.
$626.84
1111M IME, no-show fee, per examiner.
Bill only if worker fails to show and appointment time can't be filled.
Isn’t payable for no shows of IME related services (for example, neuropsychological evaluations see billing code 1139M, and performance based PCEs see billing code 1140M).
For more information, see:  WAC 296-20-010(5).
$213.40
1134M IME late cancellation fee, per examiner
Bill only if worker fails to show and appointment time can't 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).
$213.40
1112M IME, additional examiner for IME
Use where input from more than 1 examiner is combined into 1 report. Includes:
  • Record review,
  • Exam, and
  • Contribution to combined report.
  • L&I expects that these exams will typically involve at least 30 minutes of face to face time with the patient.
Note: Lead examiner on IMEs with a combined report should bill a standard or complex exam code (1108M or 1109M).
$446.56
1118M IME by psychiatrist
  • Psychiatric diagnostic interview with or without direct observation of a physical exam.
  • Includes review of records, other specialist’s exam results, if any.
  • Consultation with other examiners and submission of a joint report if scheduled as part of a panel.
  • Report includes a detailed chronology of the injury or condition, as described in the Medical Examiners’ Handbook .
  • L&I expects these exams will typically involve at least 60 minutes of face to face time with the patients
  • Also includes impairment rating, if applicable.
$907.50
1120M IME, no-show fee, psychiatrist
Bill only if worker fails to show and appointment time can't be filled
Isn’t payable for no shows of IME related services (for example, neuropsychological evaluations see billing code 1139M).
For more information, see:  WAC 296-20-010(5).
$330.79
1135M IME late cancellation fee, psychiatrist
Bill only if worker fails to show and appointment time can't be filled and cancellation is within 3 business days of exam.  (Business days are Monday thru Friday.)
Isn’t payable for late cancellation of IME related services (for example, neuropsychological evaluations).
$330.79
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 :
  • MMI (maximum medical improvement),
  • Physical exam,
  • Diagnostic tests,
  • Rating, and
  • Rationale.
$501.49
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).
$201.67
1124M IME, other, by report
Requires preauthorization and prepay review:
  • For State Fund claims, call Credentialing and Compliance at 360-902-6818, or
  • For self-insured claims contact the self-insured employer or third party administrator. 
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:
  • For State Fund claims, call Credentialing and Compliance at 360-902-6818, or
  • For self-insured claims contact the self-insured employer or third party administrator.
$4.94
1128M Occupational disease report.
Must be requested by insurer.
Examples of conditions which L&I considers occupational diseases are:
  • Occupational carpal tunnel syndrome,
  • Noise-induced hearing loss,
  • Occupational dermatitis, and
  • Occupational asthma.
The legal standard is different for occupational diseases than for occupational injuries.
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.
$186.51
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:
  • Medical files,
  • History,
  • Report of Accident,
  • Re-open Application, and
  • Other documents specified by claim manager or requestor.
Bill per examiner.
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 .
$1.02
1130M

IME, terminated exam
Bill for exam ended prior to completion.
Requires file review, partial exam by the examiner and report (including reasons for early termination of exam).

Note: A partial exam is face to face time between the examiner and the worker where, at a minimum, the worker's history is obtained.

$357.24
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:
  • Report of Accident,
  • Reopen application,
  • History,
  • Medical files,
  • Other documents specified by claim manager or requestor.
Note: This fee isn’t payable if paper copies of records are provided.
$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.
$59.76
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 worker fails to show and appointment can't be filled.
$896.74
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 worker fails to show and appointment can't be filled.
$286.85
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 preauthorized by State Fund claim manager or self-insured employer/third party administrator.
$101.61
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.
$203.21
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 preauthorized by State Fund claim manager or self-insured employer/third party administrator.
$304.82

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/.

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. For psychiatrists examiners, the limit is 8 per day. A Psychiatric examiner must spend at least 60 minutes of face time with the worker.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.

Back to top

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://app.leg.wa.gov/wac/default.aspx?cite=296-20-010
Administrative rules
for impairment ratings
WAC 296-20-2010:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-2010
Application to become
an IME provider
(State Fund)
L&I’s website:
http://protodev.lni.wa.gov/FormPub/results.asp?Keyword=245-046-000&Submit=Search&SubSection=&DocType=0
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/
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:
http://www.lni.wa.gov/FormPub/results.asp?Keyword=F252-001-000
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 © 2012 American Medical Association

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.