Practice Management Alert

Patient's Name:
POL#:
DOS:
Claim #: To [name of decision-maker] at [insurance carrier]: I am writing to appeal the above-referenced claim that was denied on ______. A significant, separately identifiable E/M service was rendered and documented on the same day by the same physician who performed [the minor procedure or diagnostic test - list the code and descriptor]. Modifier -25 was appended to the E/M code to identify that this was a separate service. Not only was the E/M service significant and separately performed and identifiable, but it was necessary to provide the patient with quality care and to determine that there was a medical necessity for [minor procedure or diagnostic test - list the code and descriptor]. The physician deserves to be fairly reimbursed for the E/M service provided as well as for [minor procedure or diagnostic test - list the code and descriptor]. Enclosed is medical-record documentation to support the E/M service [list the code and descriptor] as well as [minor procedure or diagnostic test - list the code and procedure]. Please review these records and promptly send us the correct reimbursement. I thank you in advance for your prompt attention to this matter. Sincerely,
[your name, your title] *It's important to address this letter to a specific person who handles appeals so you have a contact to follow up with.

Template supplied by Erica Schwalm, reimbursement specialist; edited by Catherine Brink, CMM, CPC.