Sample Letter for Medicare Carrier X-Ray-ECG Interpretation Denial

Date


Attn:
Appeals Department
Address
City, State, ZIP Code

Re:  Emergency Medicine X-ray/ECG Interpretation

 

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

Dear Sir/Madam.:

The original claim for the Medicare beneficiary identified above was submitted correctly for X-ray/ECG interpretation. 

The following information is provided to clarify X-ray interpretation billed by ________________________ Emergency Medicine physicians, from the CMS Final Rule published in the Federal Register December 8, 1995:

Effective for services furnished beginning January 1, 1996, the policy on payments for the interpretation of an X-ray or an EKG furnished to a Medicare beneficiary in an emergency room by a hospital's radiologist or cardiologist, respectively, has been changed to permit payment for the interpretation to either the specialist or the treating physician. As a part of the revised policy, HCFA made a regulatory change specifying that the professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary's medical record maintained by the hospital. (See 42 CFR 415.120(a).)
Pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. Cease consideration of physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Do not consider designation as the hospital's "official interpretation" a factor in determining which claim to pay. Pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary.
If the first claim received is from a radiologist, pay the claim because you would not know in advance that a second claim would be forthcoming. When you receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, pay that claim. Determine that the radiologist's claim was actually quality control and institute recovery action.

Please remit payment per CMS policy.  Thank you for your prompt attention to this matter.  Please contact [staff name] at [telephone number] in our office should you have any questions regarding this claim.


Sincerely,


[Physician Name]

 

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