Downcoding of E/M Services Based on ICD-10 Diagnostic Code Sample Letter

Provider Appeals Department
City, State, ZIP Code

Re: Denial based on ICD-10 diagnosis


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

Dear Sir/Madam:

[insert org name here], is deeply concerned about [Ins. Co's name] down coding of Evaluation and Management (E/M) levels based on the submitted ICD-10 diagnostic codes.  We are writing this letter to request [name of addressee organization] change your policy immediately and base payment of claims on the proper application of coding guidelines as presented in the Current Procedural Terminology (CPT) Manual.

The American Medical Association encourages consistency in the choice of CPT codes and has provided instructions for proper code determination in the introduction of the CPT Manual. Physicians are to select the procedure or service that "accurately identifies" the physician services performed.  The key components that determine the appropriate CPT E/M code choice for emergency medicine are the extent of history, examination, and medical decision making.

The AMA defines MDM in the Evaluation and Management (E/M) Services Guidelines section of the CPT manual as the complexity of establishing a diagnosis and/or selecting a management option as measured by:

  • "The number of possible diagnoses and/or the number of management options that must be considered;
  • "The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed;
  • "The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and /or the possible management options.

Patients requiring evaluation and therapy that have proper documentation should be reported with E/M codes that reflect these efforts. These E/M code choices should not be altered or discounted based on the patients' final diagnosis - a methodology that is never used to determine CPT code choice, and which should not be used either to discount a physician's efforts in arriving at an end-of-encounter diagnosis or to deny legitimate claims.

The emergency physician has very little past history about the patient on initial presentation, is required by federal law to determine the existence of an emergency medical condition in a timely manner, and must tailor his/her evaluation and management to the presenting complaint(s).
The final ICD-10 diagnosis only represents an endpoint after a thorough evaluation and in no way accurately describes the work expended by the emergency physician. Furthermore, the ICD-10 codes were never intended to deny or modify accurately assigned ED E/M levels. If [insert org name here] believes that it is appropriate to downcode or deny an ED E/M service based on a diagnosis, we ask you to provide us both the basis of this policy and a comprehensive list of diagnoses that would result in a change or denial of a submitted ED E/M code.

We request that you immediately change your policy of denying payment or decreasing E/M code levels based on diagnostic or ICD-10 code choice submitted. If this aberrant adjudication policy is based on internal (payers name) policy other than CPT, we are eager to understand the reasoning that resulted in this policy and how it can in any way accurately choose appropriate E/M code levels. In the interim, if you have any questions, or would like additional information, please contact [your contact person] at [phone number].

Thank you for your prompt attention to this very important manner.


[Physician  name]


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