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

ID #                
Date of Service:                
Claim #                

Dear Appeals Department:

The claim was originally submitted without modifer -25. We are resubmitting this claim as a
corrected claim with modifier -25.  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.

she/he had rendered to your member.
she/he had rendered to your member.

Kindly see attached corrected and resubmitted claim. We anticipate reconsideration of this denial
and claim payment soon.

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!
Sample Claim Appeal Letter without Modifier 25