CPT Code 97039 again

“By Report” CPT Code Documentation Requirements in No-Fault Cases

The workers’ compensation fee schedule adopted for New York No-Fault Insurance Law purposes assigns specific relative values to most Current Procedural Terminology (CPT) codes, allowing for standardized reimbursement calculations. However, certain CPT codes carry a “By Report” designation rather than a predetermined relative value. This designation requires healthcare providers to submit additional documentation beyond standard claim forms to enable insurers to determine appropriate reimbursement amounts.

CPT Code 97039 falls into this “By Report” category, creating recurring disputes about what documentation insurers can demand and what procedures they must follow when providers fail to submit the additional information. The critical question addressed in this case is whether an insurer can deny a claim outright for failure to provide “By Report” documentation without first requesting the missing information through proper verification procedures.

Case Background

Acuhealth Acupuncture, P.C. v Hereford Ins. Co., 2017 NY Slip Op 51871(U)(App. Term 2d Dept. 2017)

The plaintiff medical provider submitted claims for services billed under CPT code 97039, which carries a “By Report” designation under the workers’ compensation fee schedule. The defendant insurer denied the entire claim, asserting that the provider failed to submit the additional documentation required for “By Report” codes. The Civil Court granted summary judgment to the defendant dismissing the claims for CPT code 97039 services, and the plaintiff appealed.

Jason Tenenbaum’s Analysis:

“As limited by its brief, plaintiff appeals from so much of the Civil Court’s order as granted the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT code 97039 and denied the branch of plaintiff’s cross motion seeking summary judgment on so much of the complaint as sought to recover for those services.

It is undisputed that defendant denied plaintiff’s claim for services billed under CPT code 97039 in its entirety. The workers’ compensation fee schedule does not assign a relative value to this code, but instead has assigned it a “By Report” designation, which requires a provider to furnish certain additional documentation to enable the insurer to determine the appropriate amount of reimbursement. Defendant’s denial is based upon plaintiff’s failure to provide such documentation with its claim form. However, 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 CPT code 97039, defendant was not entitled to summary judgment dismissing so much of the complaint as sought to recover for services rendered under that code (see Gaba Med., P.C. v Progressive Specialty Ins. Co., 36 Misc 3d 139, 2012 NY Slip Op 51448 ; see generally Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132, 2009 NY Slip Op 50732 ).”

This is a silly basis to deny a bill.

Legal Significance of Verification Requirements for “By Report” Codes

The Appellate Term’s ruling establishes that insurers cannot deny claims for “By Report” CPT codes based solely on the provider’s failure to submit additional documentation with the initial claim form. Instead, the insurer must first request the missing information through proper verification procedures under 11 NYCRR 65. This holding protects providers from outright denials when insurers could have obtained the necessary documentation through verification requests but failed to do so.

The decision reflects broader principles governing no-fault insurance claim processing: insurers must exercise their verification rights before denying claims on procedural grounds. The “By Report” designation indicates that additional information may be necessary, but it does not eliminate the insurer’s obligation to seek that information through established regulatory procedures. Courts will not permit insurers to use the “By Report” designation as a trap for unwary providers who submit otherwise complete claim forms.

Practical Implications for Attorneys and Litigants

Medical providers billing for “By Report” CPT codes should understand that while they may need to provide additional documentation, insurers cannot summarily deny claims without first requesting the information. When defending against denial-based summary judgment motions, providers should examine whether the insurer issued proper verification requests seeking the “By Report” documentation. If no such request was made, the denial cannot be sustained as a matter of law.

Insurance carriers must revise their claim handling procedures for “By Report” codes to ensure compliance with verification requirements. Rather than denying these claims outright, insurers should issue verification requests specifically identifying what additional documentation is required to determine appropriate reimbursement. Only after providers fail to respond to proper verification requests can insurers deny claims on the basis of insufficient “By Report” documentation. This procedural safeguard prevents premature denials while still allowing insurers to obtain necessary information for proper claim adjudication.

Related Articles

• Understanding Medical Billing and Down-Coding in New York No-Fault Insurance Claims
• Fee Schedule Defense Requirements in No-Fault Insurance Cases
• Fee schedule defense – competent evidence?
• First application of 11 NYCRR 65-3.8(g)(1)(ii)
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2017 decision, New York’s no-fault fee schedules and “By Report” designation procedures for CPT codes may have been substantially revised through regulatory amendments. Practitioners should verify current fee schedule provisions, documentation requirements, and insurer verification procedures, as reimbursement protocols and procedural requirements have likely evolved significantly over the intervening years.