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Incorrect Reimbursement: E/M Downcoding

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 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: 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

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 the 1995 AMA CPT guidelines, two of three key components (history, examination, and medical decision making) determine established patient evaluation and management (E/M) level. In the case where counseling and/or coordination of care dominates the physician/patient encounter, time is the controlling factor to qualify for a particular level of E/M service.

Optional: Attached is a copy of an OVERTURN IBR decision, including the guidelines used to evaluate appropriate 99214 E/M level.  This IBR decision indicates that this reimbursement will be overturned when reviewed by IBR.

Recommended Supporting Documents

Other Second Review Topics

We hope that helps!

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