Medicare Compliance & Reimbursement

Even if you follow all of CMS's rules in reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), your Medicare payer may sometimes still choose to deny your claim.

If you feel you deserve the pay for the E/M service you performed, you should appeal the denial. Alice Kater, CPC, PCS, coder with Urology Associates of South Bend in Indiana, offers the following sample appeal letter (below) as an example of how she has challenged her payer to collect rightful reimbursement.

What you should know: To improve her odds of success, Kater submits her physician's documentation with the appeal letter, as well as a copy of a 2005 letter from Mark B. McClellan, MD, PhD, former HHS administrator, to Inspector General Daniel R. Levinson that was a response to the 2005 OIG report "Use of Modifier 25." In addition, Kater includes the first three pages of the OIG report, which outlines the appropriate way to report modifier 25.

(Editor's note: You can download McClellan's letter, as well as the OIG report, at: www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.)