A medical-legal evaluation in California work-comp — a QME, AME, or IME report ordered to resolve a contested issue — is reimbursed under the Medical-Legal Fee Schedule (MLFS), codified at CCR §9795. It is a world of its own: a small set of ML codes, a record-review code, and a modifier system that behaves unlike anything in ordinary CPT billing.
The ML codes
The current schedule collapsed the old library into a handful of flat-fee codes built around evaluation complexity:
| Code | What it covers |
|---|---|
ML200 | Missed appointment (a no-show evaluation that still incurs cost). |
ML201 | Follow-up evaluation by the same evaluator. |
ML202 | Comprehensive medical-legal evaluation — the workhorse code. |
ML203 | Comprehensive evaluation involving extraordinary circumstances. |
ML204 | Supplemental medical-legal evaluation. |
ML205 | Sub rosa / surveillance-record review. |
MLPRR | Records review beyond the pages included in the base evaluation — billed per page over the threshold. |
The modifier stack — where the money is
This is the part that trips up generalist billers. MLFS modifiers 92 through 98 are not flat add-ons. They are multipliers, and when more than one applies they compound rather than add. The base ML code allowance is multiplied by each applicable modifier's factor in sequence.
- Modifier 93 — the evaluator is the primary treating physician.
- Modifier 94 — the evaluator performed the evaluation as an AME or panel QME.
- Modifier 95 — an interpreter was needed at the evaluation.
- Modifiers 96 / 97 / 98 — apply to specific evaluation circumstances and timing.
Because the factors multiply, the order and the combination matter to the penny. If your billing software adds modifier percentages instead of compounding them, every modified bill will be under-calculated — and you'll never know unless you check each EOR against an independent calculation.
Rule of thumb: for MLFS, modifiers 92–98 multiply, they do not add. Stacking modifier 94 and modifier 95 on an ML202 yields a compounded allowance, not the sum of two flat bumps. This single rule accounts for a large share of med-legal underpayments.
MLPRR and the page-count attestation
The base ML202 allowance includes review of a set number of pages. Records beyond that threshold are billed under MLPRR at a per-page rate. MLPRR is one of the most-rejected lines in all of med-legal billing — almost always because the bill is missing the LC §4062.3 sender declaration, the signed page-count attestation that documents how many pages were served and reviewed. Without it, the payer rejects the extra pages outright. Attach the declaration to every MLPRR bill and most of those rejections disappear.
Why pricing live against §9795 matters
The MLFS allowance for a given report is fully determined by the ML code and the modifier stack. That means it can be calculated before the bill ever goes out — and re-calculated the moment the EOR comes back. When the allowed amount on the EOR is less than the §9795 figure, you have a documented underpayment and a clean basis for a Second Review. The schedule is rigid by design; use that rigidity in your favor.
This guide is general information for California workers'-comp and med-legal billers, not legal advice. Statutes, fee schedules, and forms change — confirm against the current DWC regulations for your dates of service.