Denial Incorrect: PTP E/M Visit

For incorrectly denied or underpaid Original bills, DaisyBill advises filing a Second Review and including IBR decisions as supporting documentation.

For help determining the correct level of E/M code code and documentation, read DaisyBill’s Work Comp FAQ article: E/M Code Determination: How do I know the right code level for E/M services?

Official Medical Fee Schedule

Physician Services

CPT Code(s)

99213-99215

99203-99205

Payable

Yes

EOR Denial Reason

This service requires prior authorization and none was identifed.

Second Review Reason (SBR-1 Form)

Recommended Reason

Evaluation and Management visits do not require prior authorization when performed by the designated Primary Treating Physician (PTP).

Optional: Attached is a copy of an OVERTURN IBR decision indicates that this reimbursement will be overturned when reviewed by IBR.

Recommended Supporting Documents (IBR Decisions)

DaisyBill Resources

Webinar: Requests for Second Review

Webinar: Second Review Strategy Kit, Part I

Webinar: Second Review Strategy Kit, Part II

DaisyBill Solution

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.

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