When an original bill is incorrectly denied or underpaid, daisyBill advises filing a request for 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 your request for Second Review reasons, use daisyBill’s Second Review Reasons. For incorrectly denied procedure codes 99358 / 99359, we recommend language similar to the Second Review reason below.
There are no specific reporting requirements for non-face-to-face prolonged services. Nonetheless, when non-face-to-face prolonged services are rendered, we strongly recommend including documentation especially explaining the circumstances for the prolonged non-face-to-face services..
For dates of service on or after 4/1/17, Medically Unlikely Edits (MUE) recommend a maximum reimbursement of one unit of 99358 and two units of 99359 of non-face-to-face time per patient on any given day.
Official Medical Fee Schedule
EOR Denial Reason
- Insufficient documentation, there is nothing in medical record to substantiate billed charges. The narrative does not include records reviewed.
- The charge was denied as the report / documentation does not indicate that the service was performed.
Second Review Reason (SBR-1 Form)
For dates of service on or after 3/1/2017 99358 and 99359 are assigned a Medicare Status Code of "A" Active Code. Per § 978912.8, “These codes are paid separately under the physician fee schedule.” Further, for non-face-to-face prolonged services, the DWC does not provide specific reporting requirements. This billing for CPT 99358 and, if applicable, CPT 99359, meets all the criteria for prolonged service without direct patient contact, as set forth in the American Medical Association’s CPT definition.
Recommended Additional Information
- Blog: The 5 Point Checklist for CPT Codes 99358 and 99359
- IBR Decision CB21-0000599
- IBR Decision CB21-0000286
- IBR Decision CB21-0000491
- IBR Decision CB21-0000151
Other Second Review Topics
We hope that helps!