Health care providers (HCPs) play a key role in New Mexico's workers' compensation system. Authorized HCPs are any medical care providers licensed in New Mexico or otherwise approved by the WCA Director, including surgeons, psychologists and physical therapists. In addition to helping injured workers recover from injuries to return to work, the HCP also offers opinions that affect claims and benefits.
Find out more in our Health Care Provider Guide.
AMA Guides Changes
The American Medical Association (AMA) Guides for evaluating impairment have changed. According to the New Mexico Workers’ Compensation Act 52-1-24 NMSA 1978 A, impairment is “based upon the most recent edition of the American Medical Association’s (AMA) Guide (the Guides) to the Evaluation of Permanent Impairment.” This reference can also be found in Workers’ Compensation Administration (WCA) Rules 184.108.40.206 V and 220.127.116.11 G.
Effective July 1, 2021, the AMA considers AMA Guides Sixth 2021 to be the most current version of AMA Guides Sixth. Going forward, the AMA Guides be revised yearly and maintained exclusively online at https://www.amaguides.com
To assist our stakeholders to better understand these changes, you may refer to the following links below which include a prerecorded webinar by the AMA and a synopsis of the changes:
• AMA Guides Sixth 2021 Education Module
• Description of Changes- AMA Guides Sixth 2021
• AMA Guides Medical Seminar (April 2021)
• What’s New to the AMA Guides (2021 and 2022)
• AMA Guides Frequently Asked Questions
You may also refer to the NM WCA Quarterly Bulletin for Summer 2021 on the agency website, attached here: https://workerscomp.nm.gov/sites/default/files/documents/publications/bulletins/Summer2021.pdf
Further, the AMA, in partnership with the New Mexico Medical Society (NMMS), hosted a virtual LIVE webinar especially for the NM legal and medical community which is linked here:
A passcode is needed to view the recording. Access Passcode: A5=IHKSQ
Interested in Becoming an Independent Medical Examiner (IME)?
Independent Medical Examinations (IMEs) are neutral medical exams provided in certain workers' compensation cases where medical issues need clarification. IMEs can be performed by a single physician or a panel of physicians and specialists. IMEs can be requested by any party, or ordered by a workers' compensation judge.
Interested in becoming an IME provider? The WCA approves providers for independent medical examinations (IMEs) through a process. The application process is open March 1 through May 31 each year.
Find the current list of IME providers.
Health Care Provider (HCP) Fee Schedules
The WCA's Medical Cost Containment Bureau implements various cost-saving measures for medical services provided to injured or disabled workers. The bureau publishes a fee schedule that governs payment for outpatient services.
The Health Care Provider Fee Schedule (HCPFS) is issued annually by the WCA to set costs for medical procedures. Health care providers are normally limited to receiving payments within the range of the HCPFS. Hospital stays require pre-authorization.
WCA Director Issues Telemedicine Directive
Then-WCA Director Loretta Lopez issued a Director's Order regarding the use of telemedicine in workers' compensation medical cases. This order became effective on March 25, 2020 and remained in place until implementation of the 2021 Health Care Providers' Fee Schedule, on January 1, 2021.
Director Issues CPT Code Directive for COVID-19 Testing
WCA Director Loretta Lopez issued a Director's Order on July 28, 2020, which supplemented the 2020 WCA Health Care Provider Fee Schedule, and recognized Current Procedural Terminology (CPT) code 87635, at a maximum allowable rate of $91.13. The code for COVID-19 diagnostic testing was added by the American Medical Association to the CPT 2020, Professional Edition, effective March 13, 2020.The order remained in place until the WCA implemented the 2021 fee schedule effective January 1, 2021.
In the 2019 Health Care Provider Fee Schedule and Billing Instructions, there was an omission of text on page 14, under "Materials and Supplies." The last statement in that section should read:
"Materials and supplies provided during a hospital inpatient stay, hospital outpatient treatment or surgery, or emergency room visit shall be reimbursed based on the appropriate hospital ratio."
The correction is retroactive to January 1, 2019.
Provider's Report of Physical Ability (PROPA), a form initiated in the 2018 Fee Schedule.
For the method of payment for Freestanding Ambulatory Surgery Centers, please see page 10 of the Fee Schedule and Billing Instructions.
Ratios Effective January 1, 2019 can be found on page 11 of the Fee Schedule and Billing Instructions document.
Release for Health Care Records
In a workers' compensation case, it may be necessary for a worker to allow a HCP to disclose medical records for the purposes of facilitating and evaluating a workers' compensation claim.
Find the form for Authorization for Use and Disclosure of Health Records.
Approval of Out of State Health Care Provider Forms and Letter
The following forms are downable by clicking on the corresponding document. The forms are also available on our forms page.
Official Disability Guidelines
On July 1, 2013, the Work Loss Data Institute's (WLDI) Official Disability Guidelines (ODG) went into effect in New Mexico for the treatment of workers' compensation injuries. All medical services rendered for recommended treatment contained in the most recent edition of Official Disability Guidelines (ODG) are presumed reasonable and necessary.
Read more about the Official Disability Guidelines.
Return to Work
The goal after a workplace illness or injury is getting back to work as quickly as possible. Even if an immediate return to the job isn't possible, light or flex duty may be possible, provided the treating health care provider recommends it and the employer has such work available. The longer a worker is out of work, the greater the chance of never returning to the job.
Find out more about Return to Work.