Fillable Printable De 2546Y

De 2546Y

DE 2546Y Rev. 18 (7-06) (INTERNET) Page 1 of 2 CU

Medical Examiner Information

To determine a claimant's continuing eligibility for Disability Insurance (DI) benefits, we

sometimes request an examination and opinion of an impartial doctor. The examination

needs only to be extensive enough to determine if the claimant is able to perform his or her

regular or customary work, and on what date he or she is, or will be, able to do so.

IF YOU DO NOT DESIRE TO PERFORM THIS EXAMINATION, PLEASE RETURN OUR

REQUEST WITH A NOTE TO THAT EFFECT.

If your examination requires laboratory and/or X-ray work from another source, please

provide the fee schedule on the back of this form to the external source so that they are

aware of what we are permitted to pay.

A fee of $83.30 has been established for this type of examination plus the cost of any

laboratory and/or X-ray investigation necessary to aid in arriving at an opinion. (See reverse

for a detailed listing of X-ray and laboratory fees.)

Billing Instructions

Invoices. We encourage use of the Independent Medical Examination Invoice,

DE 2546INV, provided. If you do not use the DE 2546INV, your invoice should be on a

printed billhead. If you do not use either the DE 2546INV or a preprinted billhead, or if

the preprinted billhead has been altered in any way, the doctor's personal signature must

appear on both copies of the invoice.

Note: Invoices not submitted on the DE 2546INV enclosed with the Request for

Examination must be submitted in duplicate - one original and one copy.

Bill to: "State of California, Employment Development Department." Use the address

shown on the Request for Medical Exam. Do not use individual names such as the office

manager or an office representative.

X-Ray and Laboratory Invoices. Billing for any authorized laboratory or X-ray work

associated with the examination should accompany your invoice and report. Charges for

laboratory work or X-rays may be included in one invoice or billed separately by the

laboratory. Invoices should reflect fees per the California Workers’ Compensation Official

Medical Fee Schedule published by the California Department of Industrial Relations. On

the invoice, briefly describe the type of laboratory work performed and the number of X-ray

views taken. The reverse side of this form shows a partial fee schedule for X-ray and

laboratory billing.

Claimant Information. The claimant's name, Social Security Account number, and the

date of examination should appear on the invoice.

Employer Identification Number. Your Federal Employer Identification Number (FEIN)

assigned by the Internal Revenue Service or your Social Security Account number must

appear on the invoice.

CPT Codes appear in parentheses after each procedure.

DE 2546Y Rev. 18 (7-06) (INTERNET) Page 2 of 2 CU

X-Ray

Skull, less than 4 views

with or without stereo (70250) .................... $47.50

Chest, single view (71010) ................................. 40.00

2 views (71020) ............................................ 47.50

Ribs, unilateral (71100) ...................................... 55.00

Bilateral (71110) ........................................... 67.50

Spine, entire, survey study

(A-P & lateral) (72010) ............................... 100.00

Cervical A-P & lateral (72040) ...................... 55.00

Thoracic, minimum of 2 views (72070) ........ 55.00

Thoracolumbar, A-P & lateral (72080) ......... 55.00

Lumbosacral, A-P & lateral (72100) ............. 55.00

Pelvis, A-P only (72170) .................................... 46.25

Complete, minimum of 3 views (72190) ....... 61.25

Clavicle (73000) ................................................. 50.00

Shoulder, one projection (73020) ...................... 43.75

Complete study (73030) ............................... 56.25

Humerous, including one joint (73060) .............. 46.25

Elbow, A-P & lateral (73070) .............................. 41.25

Wrist, A-P & lateral (73100) ............................... 36.25

Complete study, min 3 views (73110) .......... 47.50

Hand (73120) ...................................................... 37.50

Fingers (73140) .................................................. 28.75

Hip, one view (73500) ........................................ 38.75

Complete study (73510) ............................... 50.00

Femur, including one joint (73550)..................... 47.50

Knee, 2 views (73560) ........................................ 43.75

Complete study, min 3 views (73564) .......... 58.75

Tibia & fibula, including one joint (73590) ......... 47.50

Ankle, 2 views (73600) ....................................... 43.75

Complete study, min 3 views (73610) .......... 45.00

Foot, 2 views (73620) ......................................... 43.75

Complete study, min 3 views (73630) .......... 46.25

Toes (73660) ...................................................... 35.00

Gastrointestinal Series

Colon, Barium enema (74270) ......................... 130.00

Cholecystography, oral dye (74290) ................ 63.75

Upper gastrointestinal tract,

with or without delayed time (74240) ........... 96.25

Urine

Routine chemical, qualitative

(sugar, protein, acetone, etc.) (81005) ........... 7.80

Complete routine

(chemical and microscopic) (81000) ............ 11.25

Electrocardiogram

With 12 leads and interpretation (93000) ................ 49.20

With stress test- continuous

monitoring (93015) .......................................... 210.33

Blood

Complete blood count (85031) ............................ 19.50

Hemoglobin determination colorimetric (85018) ..... 8.70

White cell count (85048) ........................................... 8.70

Red blood count (85041) .......................................... 8.70

Syphilis

Qualitative (VDRL flocculation, etc.) (86592) .... 11.70

Quantitative (86593) .......................................... 12.60

Sedimentation rate (85651) ................................... 12.15

Hematocrit (packed cell volume

or PCV) (85014) ............................................ 8.70

Transaminase, AST, SGOT (84450) ................. 14.55

ALT, SGPT (84460) .................................... 15.00

Blood chemistry - automated, multichannel

(Alanine aminotransferase [ALT, SGPT]; Albumin;

Aspartate aminotransferase [AST, SGOT];

Bilirubin, direct; Bilirubin, total; Calcium;

Carbon dioxide content; Chloride; Cholesterol;

Creatinine; Glucose; Lactate dehydrogenase;

Phosphatase, alkaline; Phosphorus [inorganic

phosphate]; Potassium; Protein, total; Sodium;

Urea nitrogen; Uric acid)

Any 3 tests (80003) ........................................... 19.50

Any 4 tests (80004) ........................................... 23.40

Any 5 tests (80005) ........................................... 24.30

Any 6 tests (80006) ........................................... 25.35

Any 7 tests (80007) ........................................... 26.25

Any 8 tests (80008) ........................................... 28.20

Any 9 tests (80009) ........................................... 29.10

Any 10 tests (80010) ......................................... 30.15

Any 11 tests (80011) ......................................... 31.05

Any 12 tests (80012) ......................................... 32.10

Any 13 through 16 tests (80016) ....................... 36.90

Any 17 through 18 tests (80018) ....................... 37.95

Any 19 or more tests (80019) ............................. 38.85