Sample Letter for Non-Medicare X-Ray-ECG Interpretation Bundled into Evaluation and Management Code

Date

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

Re: Bundling of X-ray Interpretation/ECG with Emergency Medicine Evaluation/Management Code

 

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

Dear Sir/Madam:

The following information is provided to clarify the charge for [X-ray or ECG] interpretation provided by [Emergency Medicine Physician], Emergency Medicine Department, as a distinct and separate service identifiable from the Evaluation/Management services also provided during the patient encounter. 

The original claim for the insured patient identified above was submitted correctly for both [X-ray or ECG] interpretation and Evaluation/Management services provided in the Emergency Department.  The [X-ray or ECG] interpretation was medically necessary due to the patient's presenting problem.  In addition to the [X-ray or ECG] interpretation, this patient also received separately billable E/M services including history, examination, and medical decision making in the Emergency Department.  The E/M code, [9928x], was billed with a -25 modifier indicating the significant, separately identifiable Evaluation/Management service.

CPT® is the designated code set determined by HIPAA. CPT® states, "The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services.  Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code."1

Please forward this information to your medical review staff for an independent determination to prevent a computer-generated denial based on coding edit software that routinely occurs with these claims.

Thank you for your consideration. Please contact [staff name] at [telephone number] in our office should you have any questions regarding this claim.

Sincerely,


[Physician Name]

 

1 American Medical Association, Current Procedural Terminology 2006, Professional Edition. (Chicago: AMA, 2005), p. 2.
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