Provider Appeals Department
City, State, ZIP Code
Re: Bundling of X-ray Interpretation/ECG 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 [X-ray or ECG] 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 [X-ray or ECG] interpretation and Evaluation/Management services provided in the Emergency Department. The [X-ray or ECG] interpretation was medically necessary due to the patient's presenting problem. In addition to the [X-ray or ECG] 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.
|1||American Medical Association, Current Procedural Terminology 2006, Professional Edition. (Chicago: AMA, 2005), p. 2.|