Late last month, we examined a particularly intriguing CPT Code – 0232T – as part of our ongoing investigation into when reimbursements are established “By Report.” For certain codes, including HCPCS 0232T, the Physician Fee Schedule provides no established reimbursement amount, essentially allowing providers to set their own price – as long as they can back it up with proper supporting documentation.
On top of that, 0232T is a Level III code, per the Current Procedural Terminology (CPT). This denotes a temporary code – its usage is being closely monitored by the CMS, and it will likely shed its temporary status at some point and become a Level I code with a set reimbursement amount. Until then, the “By Report” reimbursements are frequently mishandled by claims administrators. The provider’s best recourse for this all-too-common scenario is submitting the bill for Second Review and attaching an Independent Bill Review (IBR) case as support.
DaisyBill’s billing software includes an IBR database with over 7,800 IBR decisions. Thirty-nine of those decisions concern CPT Code 0232T. We’ll analyze one of those decisions in a moment. But before we do, a brief recap of the billing requirements for codes designated as “By Report.”
Once a provider verifies that the reimbursement for a procedure code is By Report, they should turn to California Code of Regulations § 9789.12.4 for billing instructions. This regulation instructs the provider to establish a reimbursement and to submit a separate, non-reimbursable report to justify the reimbursement value. The report must:
- Prove “that the service was reasonable and necessary to cure or relieve from the effects of the industrial injury or illness.”
- Describe the procedure in as much detail as possible, including information about
- the length of the procedure,
- any equipment used, and
- the level of expertise or skill needed to perform the procedure. This information should be submitted via a separate, non-reimbursable report.
IBR decisions concerning BR codes provide useful insight into the billing requirements necessary to succeed at the highest level of appeal. Let’s analyze a representative sample.
Synopsis and EOR
The provider requested reimbursement for CPT 0232T at a rate of $1600, subject to a 5% PPO discount, in addition to reimbursement for procedure code A9999. The claims administrator denied the reimbursement for 0232T, stating in the EOR that it is “included in the surgery procedure,” and not-so-astutely noting that “this is an unlisted procedure.” The claims administrator also requested that the provider resubmit the bill with a different procedure code.
In the IBR documentation sent to MAXIMUS Federal Services, the provider included the claims administrator’s utilization review decision acknowledging the receipt of a compliant RFA and the subsequent authorization of the requested 0232T treatment.
MAXIMUS reviewed an attached contractual agreement between the provider and the claims administrator and noted that the agreement did not contain a reimbursement formula for unlisted or “by report” codes. Less such a reimbursement formula, the IBR panel directed that “by report” codes “are reimbursable at the Provider’s Usual and Customary Charge.”
MAXIMUS Federal Services overturned the claims administrator’s refusal to reimburse for procedure code 0232T.
Additional Reimbursement Due
In the final determination, the claims administrator was required to remit $1475.44 in additional reimbursement, plus $195 to cover the cost of the appeal.
Documentation is key. The provider included the EOR denying services, as well as the initial Request for Authorization and the claims administrator’s response authorizing treatment. Without documented authorization, the provider’s case would be considerably weaker. The moral? Always submit a compliant RFA before providing treatment.