Optometry Coding & Billing Alert

Published on Thu Jul 08, 2004 PDF

Use this sample letter to help appeal modifier -25 denials

A patient presents with eye pain, and the optometrist performs a full exam to find the cause. He discovers a foreign object and removes it using the slit lamp. You're justified in submitting a claim for an E/M service (the exam) with modifier -25 appended, along with a procedure code (the foreign-body removal) -- but some of your payers might not see it that way. Expect denials for at least some of your claims if you use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to justify an E/M service with another procedure on the same day. You can make your appeals process quick and easy by using this appeal letter template to collect on modifier -25 charges.

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]