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
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!