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Data! CPT 99358 Reimbursement

July 21, 2017 by Catherine Montgomery

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:

  1. Documenting the amount of time spent on non-face-to-face services is critical to receiving reimbursement. If you don’t report the amount of time spent, you simply won’t be paid.
  2. Even if you do document the amount of time spent on non-face-to-face services, reimbursement is spotty at best.

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 dates of service on or after 3/1/2017 99358 and 99359 are assigned a Medicare Status Code of "A" Active Code. Per § 978912.8, “These codes are paid separately under the physician fee schedule.” Further, for non-face-to-face prolonged services, the DWC does not provide specific reporting requirements. This billing for CPT 99358 and, if applicable, CPT 99359, meets all the criteria for prolonged service without direct patient contact, as set forth in the American Medical Association’s  CPT 2017 Standard Edition.”

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.

CPT CODES 99358 & 99359 WEBINAR

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