Provider Appeals Department
City, State, ZIP Code
Re: Claim adjudication, bundling of [procedure name and CPT code] with Critical Care services 99291
|Health Plan ID Number:||Group Number:|
|Insured/Plan Member:||Patient Name:|
|Claim Number:||Claim Date:|
The following information is being provided to clarify our use of [procedure name and CPT code] with the Critical Care CPT code 99291, provided as a distinct and separately identifiable procedure warranting separate reimbursement.
The emergency department patient requiring Critical Care services is the sickest in the emergency department, often requiring other procedures, as in this case when [procedure name and CPT code] was performed. According to CPT and CMS codes and guidelines, when [procedure name and CPT code] is provided additional to Critical Care service, [procedure name and CPT code] is to be billed and reimbursed separately from Critical Care code 99291. As required, the time spent performing [procedure name and CPT code] was not counted towards time spent on direct Critical Care services. The performance of the Critical Care service and [procedure name and CPT code] is clearly documented in the patient chart and should be recognized by [health plan] and eligible for payment.
Based on the circumstances of this case, we request that the [procedure name and CPT code] be considered for separate reimbursement and not bundled under payment for the Critical Care service. 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 commonly occurs with Critical Care claims.
Thank you for your consideration. Please contact [staff name] at [telephone number] in our office should you have any questions regarding this claim.