Insurer’s Burden to Request Additional Verification to Support By-Report Codes. The reimbursable fees for medical services in no-fault insurance claims are contained in the Workers’ Compensation Fee Schedule. A medical provider that bills for its services will choose the relevant CPT (Current Procedural Terminology) code whose description best describes the service being performed. Relative Value Units (RVU) are assigned for most CPT codes, and the permissible charge is ordinarily calculated by multiplying the particular RVU for that service by the applicable conversion factor. Certain CPT codes contained in the Fee Schedule, however, are not assigned a particular RVU and, instead, are denoted as “BR,” meaning By Report. General Ground Rule 3 of the Fee Schedule explains, inter alia:

By report (BR) items: “BR” in the Relative Value column represents services that are too variable in the nature of their performance to permit assignment of relative value units. Fees for such procedures need to be justified “by report.” Pertinent information concerning the nature, extent, and need for the procedure or service, the time, the skill, and equipment necessary, etc. is to be furnished …

When billing under a “BR” code, the medical provider will generally determine the fee for its service by establishing a RVU “consistent in relativity with other relative value units shown in the schedule.”