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State Compensation Insurance Fund

Per a representative, State Compensation Insurance Fund (SCIF) unveiled a “new program” with regard to billed Evaluation and Management codes (CPT codes 99201 – 99205 for new patients; 99211 – 99215 for returning patients). If the level of billed E/M service is not supported by the supporting documentation, the E/M code will now be denied and $0 will be sent as payment.

Frequently Asked Questions

Q: I received an incorrect denial from SCIF for an incorrectly downcoded E/M code. Can I still submit a Second Review?

A: Yes. If the CPT was paid at a lower rate than documented in the provided medical records, we recommend that you file a Second Review.

Q: How do I determine the correct level of E/M code and documentation?

A: Use either the 1995 or 1997 edition of CMS’ Documentation Guidelines for Evaluation and Management Services. Visit our FAQ article below for an overview of these documents.

Explanation

Previously, when SCIF bill review determined the provider’s documentation did not support the level of E/M billed, they would downcode the E/M code and pay the amount due for the downcoded E/M.

Not anymore. As reported by a SCIF representative, the E/M code will now be denied and $0 will be sent as payment if the level of billed E/M service is not supported by the supporting documentation.  

DaisyBill Resources

Help Article: Incorrect Reimbursement – E/M Downcoding

FAQ Article: How to Determine the Correct E/M Code

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