Incorrect Reimbursement: E/M Downcoding DOS Prior to 3/1/21

When an original bill is incorrectly denied or underpaid, DaisyBill advises filing a Second Review. Every request for Second Review sent 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 Review Reasons. When an E/M code is incorrectly downcoded (or paid at a lower rate), we recommend language similar to the Second Review reason below.

For help determining the correct level of E/M code code and documentation, read DaisyBill’s Work Comp FAQ article: How to Determine the Correct E/M Code DOS After 3/1/2021

Official Medical Fee Schedule

Physician Services

CPT Code(s)

99211-99215

99202-99205

Payable

Yes

EOR Denial Reason

The documentation does not support the level of service billed. Reimbursement was made for a code that is supported by the description and documentation submitted with the billing.

Second Review Reason (SBR-1 Form)

Reason for Requesting Second Bill Review (example of 99214 incorrectly downcoded to 99213)

This CPT was paid at a lower level than documented in the provided medical records. Per DWC Newsline 2021-16, E&M services no longer follow the 1995 AMA CPT guidelines as of March 1, 2021. Instead, the level of E&M office visit services are reported using either the level of medical decision making, or total time.  Provider appropriately documented report according to current guidelines.

Recommended Supporting Documents

  • All IBR decisions on this topic are currently still pending

Other Second Review Topics

We hope that helps!

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