Template Letter Downcoding EM or Consult Service
Date:
TO: Insurance Carrier Claims Review Department or
Insurance Carrier Medical Director and address
|RE: |Claim # |Date of Service: |
| |Patient Name: |Birthdate: |
I am writing regarding the aforementioned claim and your inappropriate recoding of CPT code to CPT code .
CPT guidelines indicate that in order to appropriately report an Office or Other Outpatient Service (99201-99215) or Office or Other Outpatient Consultation (99241-99245) Evaluation and Management (E/M) code, a provider must meet or exceed key components of history, physical examination, and medical decision-making for that particular code. Alternately, if greater than fifty percent of the total visit time is spent counseling and/or coordinating care, time becomes the determining factor in selecting the appropriate level code. The services provided in the above referenced claim were inappropriately downcoded. As per the attached documentation, the reported CPT code is appropriate for this encounter:
History level was Problem focused Expanded problem focused
Detailed Comprehensive
Comments:
Physical Exam was Problem focused Expanded problem focused
Detailed Comprehensive
Comments:
Medical Decision Straightforward Low Complexity
Making was Moderate complexity High Complexity
Comments:
Alternative Methodology:
Time Counseling and/or coordination of care accounted for more than 50% of the face-to-face time with the patient and/or family.
Comments:
Enclosed is a copy of the original claim that was submitted with a request that you process reimbursement as indicated on the claim. I look forward to receiving your response. If you have any questions, please feel free to contact me at
Sincerely,
................
................
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