Critical Care Service Denied in the ED Sample Letter

Date


Attn:
Provider Appeals Department
Address
City, State, ZIP Code

Re: Critical Care Services (99291) denied in the ED

 

Health Plan ID Number: Group Number:
Insured/Plan Member: Patient Name:
Claim Number: Claim Date:

Dear Sir/Madam:

The [insert your organization name here] represents Emergency Physicians (EP's) that provide care for your insured members. We are writing this letter to request that {name of addressee organization} change its policy of denying payment to physicians for critical care services, which are reported using CPT codes 99291 and 99292, when these services are provided in an Emergency Department (ED).  Denying claims for these CPT codes based on the services being provided in an ED is highly inappropriate.

Patients with critical injuries and illnesses that need emergent medical care almost always initially present to an ED.  Emergency physicians provide life and limb saving measures to these patients preventing or reducing morbidity and mortality.  We are very concerned by {insert payer name here}'s failure to follow a policy that is based on the CPT definition of critical care services.  This has resulted in physicians not being compensated for providing life saving care. 

Your organization's denial of payment for these services is contrary to CPT coding principles. The 2005 CPT, Standard Edition states that "Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility" (p 19).   Failure to recognize CPT codes 99291/99292 when provided in an emergency department is capricious, arbitrary, and entirely inconsistent with the CPT definition of these services.

Our Emergency Physicians provide critical care services to your subscribers in good faith. We respectfully request, that when medical services have been accurately reported and submitted using appropriate CPT codes, appropriate payments be made.  This would include payment for critical care services provided in the Emergency Department.

We are requesting {insert payer name here} immediately change it's policy of denying claims for CPT codes 99291/99292 when provided in an ED, as such a policy is a clear misapplication of the CPT definitions of these codes.  It would be inappropriate to support this policy by citing CPT coding as a justification.  If this policy is based on an internal {insert payer name here} policy other than CPT, we are eager to understand the reasoning that resulted in this policy.  We look forward to seeing an immediate change to your current policy, and toward future receipt of payment for providing critical care services.   Our organization is willing to discuss this concerning issue in person at a time of mutual convenience. 

In the interim, if you have questions, or would like additional information, please contact {your contact person here}.  Thank you for your time and prompt attention to this matter. 

Sincerely,


[Physician name]

 

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