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Denial Incorrect: CPT Codes 99441 - 99443 "Not Payable"

When an original bill is incorrectly denied or underpaid, DaisyBill advises filing a Second Review. Every request for Second Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-1, as well as a compliant modified CMS 1500.

To store language for Request for Second Review reasons, use DaisyBill’s Second Bill Review Library. For incorrect denials citing CPT codes 99241-99243 as not payable, use the pre-formulated Second Review reason which cites related California workers' comp regulations supporting payment.

Official Medical Fee Schedule:

Physician Services

CPT Code(s):

99241 - 99243

Payable:

Yes

Effective Date:

1/1/2014

EOR Denial Reason:

CPT code not payable per California OMFS

Second Review Reason (SBR-1 Form)

Second Review Reason Language

CPT codes 99241 - 99243 are assigned RVU values and are assigned Status Code N by the CMS National Physician Fee Schedule Relative Value File. Per § 9789.12.3 Status Codes C, I, N and R, Subsection (a) “the RVUs listed in the Centers for Medicare and Medicaid Services (CMS’) National Physician Fee Schedule Relative Value File will be utilized regardless of status code.” Accordingly, CPT codes 99241-99243 are payable per § 9789.12.2 Calculation of the Maximum Reasonable Fee.

Independent Bill Review

§ 9789.12.3 Status Codes C, I, N and R

(a) Except as otherwise provided in this fee schedule, for physician and nonphysician practitioner services billed using Current Procedural Terminology (CPT) codes, the RVUs listed in the Centers for Medicare and Medicaid Services (CMS’) National Physician Fee Schedule Relative Value File will be utilized regardless of status code.

(b) When procedures with status indicator codes C, N, or R, do not have RVUs assigned under the CMS’ National Physician Fee Schedule Relative Value File, these services shall be reimbursed By Report.

CPT Code Descriptions

99441: Telephone evaluation and management services provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 5-10 minutes of medical discussion.

99442: The same services as above with 11-20 minutes of medical discussion.

99443: The same services as above with 21-30 minutes of medical discussion.

Other Second Review Topics

Good luck!

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