Independent Medical Examiner (IME) Fee Schedule BrickStreet Insurance operates under a fee schedule for physician services. Any changes for the services listed shall be limited to the actual time involved in performing the service. Description of Service Procedure Code Fee (15 minutes = 1 unit) IME – examination – PTD X0785* $75 per unit – maximum 16 units Record Review – review of PPD treatment redirection, 120 day exam Z7776 $25 per unit – maximum 8 units (effective 7/1/2006) IME – examination for PPD, treatment redirection or 120 day referral Z7777 $75 per unit – maximum 8 units PHYSICAL PERFORMANCE TEST (Focused) 97750 $31.73 per unit – maximum 8 units FUNCT. CAPACITY EVAL – MEDICAL (Full) Z3000 $31.73 per unit – maximum 16 units No show Z7780 $200 maximum allowable EMG (needle only) Z7760 $120 maximum allowable Nerve conduction studies (needle only) Z7761 $275 maximum allowable Studies (all x-rays, etc.) Z7781 $500 maximum allowable Psychological testing (all tests) Z7785 $400 maximum allowable Basic audiological exam for IME Z7600 $50 maximum allowable Complex audiological exam for IME Z7650 $90 maximum allowable * This code expired 12/31/05 Submit bills for services on a HCFA 1500, Service Invoice (BI-400), or electronically using the appropriate procedure code. All Independent Medical Examination services must be billed in increments of 15 minutes. In order to receive the appropriate reimbursement, list the correct number of units on the bill (example: 1 hour IME exam = 4 units). Non-covered Services – When an Independent Medical Examiner bills BrickStreet for their report and includes a charge for the “Low Back Examination,” range of motion studies or other diagnostic modalities, these charges will be denied as an unbundled procedure. No Show Charges – BrickStreet will allow providers to bill for lost time when a claimant fails to appear for a scheduled Independent Medical Examination. In order to be reimbursed for such “no show” cost, the IME provider must meet the following requirements: • • • • Bill only for actual time lost, making every effort to replace the opening with normal patient “walk-ins;” BrickStreet will deny bills submitted for “no shows” when claimants have given a three or more working days cancellation notice; Maintain records of IME activities and “no shows” for possible audit and review by BrickStreet; and No report should be generated for BrickStreet if the claimant was not examined. Treatment Assessment and Impairment Rating Reports must be submitted within three weeks. Supplemental Reports must be submitted within three weeks. STAMP all reports with the words “IME Report.” The stamp is to be placed on the front of the report in the top right corner when mailing reports to BrickStreet. Diagnostic Tests – For diagnostic tests other than x-rays and psychological testing, it may be necessary to refer claimants to providers who are not associates of your office. The diagnostic tests, codes and maximum fees listed above may be used by providers who are not associates of your office when billing for IME related tests. These fees include professional and technical components. Mailing Address for Reports: BrickStreet Insurance P. O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.FormsWorkflow.com