Sample Letter for Ultrasound Denial with Bundling into E/M
Provider Appeals Department
City, State, ZIP Code
Re: Bundling of Ultra Sound Interpretation with Emergency Medicine Evaluation/Management Code
Health Insurance ID Number: Group Number:
Insured/Plan Member: Patient Name:
Claim Number: Claim Date:
The following information is provided to clarify the charge for Ultrasound] 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 Ultrasound interpretation and Evaluation/Management services provided in the Emergency Department. The Ultrasound interpretation was medically necessary due to the patient's presenting problem. In addition to the Ultrasound 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.