Evaluation and Management code selection often comes under intense scrutiny by payers.
However, just as any other denial, these denials can be appealed.
Payers provide little guidance regarding how E/M audits and denials are triggered. However, a well-worded appeal letter can seek information from the payer regarding their E/M reviews as well as information regarding the reviewer’s coding credentials.
As coders know, the correct code for an e/m visit generally is tied to the complexity of the visit. Complexity is determined by the number of problems and the extent to which each problem is addressed. This assessment requires careful manual review of the clinical documentation.
Therefore, your appeal letter must reference these specific variables with references to the supporting documentation. But, to insure that the payer provides a quality review of this information, it is also important to seek disclosure from the payer of the details supporting a continued denial and what credentials the reviewer has for overruling the treating provider’s coding selection.
The following is a Basic Evaluation and Management Level of Care appeal. Be sure and customize this letter to cite medical documentation supporting the level of care you originally billed.
Dear Director of Claims,
It is our understanding that your company has released full payment on the above referenced claim. However, the Evaluation and Management (E&M) Services code used by the provider for this date of service has been rejected or downcoded as not meeting your internal level of care billing requirements.
It is our position that the level of care is well documented in the attached medical records. As you know, E&M Services coding requires careful review of the clinical documentation for correct level of service selection. Further, the determination of complexity of medical decision making can be impacted by the number of diagnoses and management options and the amount and/or complexity of the data reviewed. Finally, high risk of significant complications, morbidity and/or mortality must be considered in level of care coding.
We request a review of this denial by a E&M coder familiar with the billed diagnoses codes and the related risks of complication, morbidity and/or mortality as noted in the medical record. If benefits remain denied, please furnish the name and credentials of the claims professional who reviewed this information. Further, please reference the credentialed coder’s licensing organization and any specialty-care coding training that the reviewer has completed. Also, please provide an outline of the specific coding criteria used to assess the claim and a description of which element of level of care billed by our office does not appear to be documented.
It is our position that failure to provide the requested information may violate state and/or federal claim processing disclosure laws or, in the minimum, non-disclosure reflects a poor quality medical process which discourages treatment provider input. Disclosure standards are meant to ensure that all qualified parties have access to the information necessary to properly appeal an adverse determination. Therefore, we appreciate your prompt, detailed response to this request.
Closing Text,
Consider further customizing this letter with direct quotes from the documentation regarding the following:
• Specifically list the diagnoses or management options addressed during the visit
• Reference the specific amount and/or complexity of data to be reviewed as indicated in documentation
• Reference any risk of significant complications, morbidity and/or mortality noted in the documentation
The following online resources may also be helpful in reviewing and appealing your E/M denials:
CMS Guidance – https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
Current AMA E/M Recommendations regarding documentation reduction –
https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
If you have had a successful E/M appeal, we would like to hear from you. Please contact Tammy Tipton at t.tipton@appealsolutions.com. We would like to share your success story with our readers.
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