Key Takeaway
Analysis of Bronx Acupuncture v Hereford case clarifying that by-report codes are verification issues, not automatic denials in NY no-fault insurance claims.
Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co., 2017 NY Slip Op 50101(U)(App. Term 2d Dept. 2017)
I recall prior to heading to a miscellaneous part in Supreme Court with guest visits to Civil Court, Judge Cohen found that a by-report code required compliance in order to make a code compesnsable or a billing overdue. I believed he was wrong and the Appellate Term confirms.
“The record reflects that plaintiff submitted three claim forms to defendant which included charges for 21 sessions of moxibustion, under code 97039, which is described as “Unlisted modality (specify type and time if there was constant attendance)” and for one session of acupressure, under code 99199, which is described as “Unlisted special service, procedure or report.” The workers’ compensation fee schedules do not assign a relative value to either of those codes, but instead have assigned them a “By Report” designation, which requires a provider to furnish certain additional documentation to enable the insurer to determine the appropriate amount of reimbursement. Plaintiff did not provide such documentation with its claim forms and defendant did not, within 15 business days of its receipt of the claim forms, request “any additional verification required by the insurer to establish proof of claim” (11 NYCRR 65-3.5 ). As defendant failed to demonstrate upon its motion that it had requested any additional verification from plaintiff seeking the information it required in order to review plaintiff’s claims for services billed under codes 97039 and 99199 of the workers’ compensation fee schedules, defendant was not entitled to summary judgment dismissing so much of the complaint as sought [*2]to recover for services rendered under those codes”
The famous by-report. The Court properly held that a by-report is verification issue. This should not shock anyone; yet, I still see denials and argument based upon the failure to adhere to the by-report guidelines.
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Legal Update (February 2026): The fee schedule provisions and “By Report” designation requirements referenced in this 2017 post may have been modified through subsequent amendments to 11 NYCRR 65-3, particularly regarding additional verification procedures under section 65-3.5. Practitioners should verify current fee schedule regulations and documentation requirements for unlisted procedure codes, as reimbursement protocols and insurer verification obligations may have been updated since this decision.
