Date

Attn:
Provider Appeals Department
Address
City, State, ZIP Code

Re: Denial or downcoding E/M levels based on ICD-10 diagnosis codes

 

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

To Whom It May Concern:

{insert org name here}, is deeply concerned about {Ins. Co's name} policy of denying payment for or downcoding 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 number and complexity of problem(s) that are addressed during the encounter, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.

Patients requiring evaluation and therapy that have proper documentation should be reported with E/M codes that reflect these efforts. 

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 diagnostic codes were never intended to effect accurately assigned ED E/M levels. 

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. 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.

Sincerely,

[Physician name]