The 2017 Physician Fee Schedule, officially adopted by the California Division of Workers’ Compensation (DWC) for dates of service on or after March 1, included the introduction of CPT codes 99358 and 99359 as reimbursable codes for non-face-to-face prolonged services such as record review. At the time, we warned that it was “likely that we will see a spike in denials of reimbursements for codes 99358 and 99359 in the coming months.”
With over four months of data in the books, we decided to follow up on our prediction. (Spoiler: We were right.)
As a quick refresher, both 99358 and 99359 have strictly-defined time components, meaning that the provider must meet half of the specified time before reporting these codes. CPT Code 99358 is for the first hour of non-face-to-face services, and may be billed before or after direct patient care. CPT 99359 is an add-on code, only billable in conjunction with 99358. So in the case of these codes, a provider must spend 30 minutes or more before billing code 99358, and 75 minutes or more before adding code 99359. As of April 1, 2017, you may report a maximum of two hours of non-face-to-face time using CPT Codes 99358 and 99359 per patient on any given day.
We took a closer look at denials and payments of 99358 and 99359 since March 1. From that date, DaisyBillers have included over 16,000 individual units of CPT Codes 99358 and 99359 in electronic workers’ comp bills. Shockingly, 55% of those units were met with a $0 reimbursement from the claims administrator.
Here’s a look at how the top 12 claims administrators by number of units of 99358 and 99359 have performed:
Claims Administrator |
Total Units 99358 and 99359 |
Number of Units Reimbursed at 0% of OMFS |
DENIED Percentage Reimbursed at 0% of OMFS |
Tristar Risk Management |
360 |
262 |
72.78% |
Travelers |
358 |
259 |
72.35% |
CorVel |
764 |
503 |
65.84% |
Gallagher Bassett |
1670 |
1016 |
60.84% |
Liberty Mutual |
621 |
376 |
60.55% |
Sedgwick |
2629 |
1575 |
59.91% |
State Compensation Insurance Fund (SCIF) |
2695 |
1464 |
54.32% |
The Hartford |
304 |
163 |
53.62% |
Zurich Insurance North America |
626 |
322 |
51.44% |
York Risk Services Group |
417 |
196 |
47.00% |
ESIS, Inc. |
502 |
190 |
37.85% |
AmTrust North America |
328 |
52 |
15.85% |
Grand Total (All Claims Administrators) |
16166 |
8605 |
53.23% |
We systematically analyzed a range of these denials to see if we could detect any commonalities among the bills that were being incorrectly reimbursed. Our takeaways are two-fold:
What does that mean? Incorrect denials on the part of the claims administrator are creating friction throughout the workers’ comp system and preventing providers from being paid. We strongly urge clients to submit their bills for second review whenever they receive an incorrect denial of 99358 or 99359 using the following language:
For more information on reporting codes 99358 or 99359, watch our webinar or download our CPT 99358 and 99359 Resource Notebook at the link below.
DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.