**Update: The 2021 OMFS updates drastically changed how E/M codes are billed.*

Reimbursements for CPTs 99358 & 99359 are tricky because payers frequently deny reimbursement for services that are not face-to-face with patients. Previously, we presented the hard data on payers who didn’t reimburse for these CPTs in 2017.

For 2018, we found 77 relevant Independent Bill Review (IBR) decisions; 42 of which overturned the payer’s denial of these CPTs. In these decisions, the provider’s documentation sways Maximus. The remaining 35 instances where Maximus upheld payer denials cite insufficient evidence or service is captured by another code.

Unfortunately, sometimes Maximus gets it wrong and renders a decision from out of left field or just plain misses the point. In our previous coverage, the provider went so far as to secure authorization for the services beforehand and was still denied payment by the bill reviewer.

Getting prior authorization is not uncommon, especially for codes reimbursed inconsistently, BUT prior authorization is NOT required for reimbursement. Further, adjusters may sign an agreement that approves such billing and then conveniently forget to give a heads up to the bill reviewers who actually process the bills.

To avoid denials of CPTs 99358 and 99359, we published a checklist to ensure success* when billing for these services.

In our review of the IBR decisions, Maximus weighed these factors when deciding to overturn the payer denials:

1. Documentation in the medical record substantiating the service.
2. Demonstration that the service that goes beyond the time spent for evaluation & management services and is not face-to-face time.
3. Equalling or exceeding 30 minutes in connection with the service to justify CPT 99358 and 75 minutes or more to justify the inclusion of at least one unit of 99359.

1. CPT 99358 covers a 60-minute block of time but requires 30 minutes or more to justify this code which can only be billed once.
2. CPT 99359 covers subsequent 30-minute blocks of time and can be billed for multiple units, provided that the final unit equals or exceeds 15 minutes

However, as the IBR decisions demonstrate, providers only have about a 54.54% success rate when it comes to appealing reimbursement before Maximus. The trend we noticed in payer decision “upheld” outcomes was that the provider failed to demonstrate the service in the medical record.

Common phrases in these decisions: “time spent could not be discerned from the records submitted,” or “report preparation is not directly related to patient care.” Translation: Careful enumeration of what, specifically, was done relevant to patient care AND ensuring the activities cannot be better captured by another billing code.

See these decisions for yourself within our searchable IBR database, which is part of DaisyBill’s Work Comp Wizard. Users can search by specific CPT codes, nature of dispute, outcome, and more. Our Work Comp Wizard also includes a handy OMFS calculator that tells you exactly how much reimbursement you should expect. Sign up for a free trial of DaisyBill’s Work Comp Wizard and see for yourself.

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