Attention: Provider Appeals
P.O. Box 0000
New York, NY 10009

ID #                
Date of Service:                
Claim #                

Dear Appeals Department:

It is my professional opinion that the above claim was unjustly processed. This letter serves our
intent to formally appeal this claim.

Per CPT, Modifier -25 is used when the patient’s condition or symptom requires Significant,
Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day
of the Procedure or Other Service.

Should you need medical notes to support medical necessity, please send us your request.  We are
more than happy to send you our medical records/notes. Otherwise, we anticipate payments within
14 days  upon receipt of this letter of appeal.

The physician deserves to be reimbursed for the service she/he had rendered to your member.

Thank you.

Jennifer Doe, BSc, CCS-P
Medical Billing Manager

*** Policies and Guidelines may differ on each insurance companies, the coding and
billing I just showed is based on Medicare Part B NY-NJ and with Horizon Blue Cross
and Blue Shield of New Jersey (as per my phone conversation with them)

*** Always consult your coding books for any questions.

*** Accurate, Real-Time and Proper Medical Documentation is very important to
support medical necessity!!! Or the service has never been done!

Reference/Source: CPT Code Book 2009 (AMA) , CPT 2009 Changes an Insider's View
CPT codes and its descriptions are copyrights, owned, maintained and is a
trademark of the AMA (American Medical Association).
*** Always consult your CPT Code Book!
*** Get more information on clinical guidelines and policies from your local CMS
carriers and from your third party payors
*** You can purchase CPT Code books and CPT Assistants issues from the
Find the answer if you don't know it! ~~
there is NO excuse for Ignorance!