Lack of Recognition of CPT Modifier 25 Sample Letter


Provider Appeals Department
City, State, ZIP Code

Re: Claim adjudication, lack of recognition of CPT modifier 25


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

Dear Sir/Madam:

The following information is being provided to clarify our use of the CPT modifier 25 reported with the CPT evaluation and management (E/M) code to indicate that a distinct and separately identifiable E/M service was performed warranting separate reimbursement.

Please be advised that the [procedure name] was not a planned procedure.  The decision to proceed with this procedure occurred after the patient's history and examination were completed.  Since this E/M service was separate from the procedure and necessary to evaluate the etiology of the patient's symptoms of [specify symptoms], separate recognition of the ED outpatient evaluation is warranted.

According to the AMA's guidelines for the appropriate use of the CPT modifier 25, it is not necessary that separate ICD-10-CM codes be reported.  Copies of the CMS-1500 claim form, procedure report and progress notes are included for review.  Additionally, according to CPT codes, guidelines and conventions, Modifier 25 is appended to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable evaluation and management (E/M) service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed (CPT Assistant: May 2003/Volume 13, Issue 5, November 2003/Volume 13, Issue 11).  The appropriateness of appending modifier 25 on the E/M CPT code [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, where the decision to perform the procedure occurred following the patient's evaluation,  we request that the E/M code be considered for separate reimbursement and not bundled under payment for the procedure.  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 CPT modifier 25 claims.

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


[Physician Name]





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