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:|
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.