Effective May 19th, 2021, WSI will make a change to the policies, Outpatient E/M Services and Other E/M Services, regarding reimbursement. If WSI determines the submitted medical documentation does not support the level of billed E/M service, WSI will deny the E/M code and remit $0 in payment. Previously when WSI determined a provider’s documentation did not support the level of E/M service billed, WSI downcoded the E/M code and paid the amount due for the downcoded E/M service.
To communicate the denial of an E/M charge not supported by the submitted medical documentation, WSI will issue a revised Reason Code 56 for the charge. The revised language will read as follows:
WSI denied this charge because the medical documentation received does not support the submitted procedure code. Either submit a corrected bill with the appropriate procedure code, or request a reconsideration by completing the Medical Bill Appeal (M6) form and submit to WSI within 30 days from the date of the remittance advice. The charge is not billable to the patient or other insurance.
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