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IV. Sample Appeal Letter: Well/Sick Same Day
Insurance Carrier Claims Review Department and address or
Insurance Carrier Medical Director and address
RE: Claim #:
I am writing regarding the aforementioned claim and (Insurance Carrier Name)’s practice of bundling pre-
ventive medicine service codes and office/outpatient service codes. Current Procedural Terminology (CPT®)
guidelines indicate that in certain cases, it is appropriate to report a preventive medicine service code (99381–
99397) in conjunction with an office/outpatient service code (99201–99215) on the same date of service.
According to American Medical Association CPT guidelines, “If an abnormality(ies) is encountered or a
preexisting problem is addressed in the process of performing a preventive medicine evaluation and manage-
ment service, and if the problem/abnormality(ies) is significant enough to require additional work to perform
the key components of a problem-oriented service, then the appropriate office/outpatient code should also
be reported. Modifier 25 should be added to the office/outpatient code to indicate that a significant, sepa-
rately identifiable evaluation and management service was provided by the same physician on the same day
as the preventive medicine service. The appropriate preventive medicine service is additionally reported.”
These statements clearly indicate that a “well” and a “sick” visit should be recognized as separate services
when reported on the same day.
Unfortunately, many carriers are not familiar with the CPT guidelines that allow for the reporting of 2 visits
on the same day of service by use of modifier 25. Further, there are no diagnosis (International Classification
of Diseases, 10th Revision, Clinical Modification [ICD-10-CM]) requirements tied to the use of modifier 25.
In fact, “The descriptor for modifier 25 was revised to clarify that since the E/M service may be prompted by
the symptom or condition for which the procedure and/or service was provided, different diagnoses are not
required to report the E/M services on the same date” (CPT Assistant. May 2000;10[5]). This basic tenet of
CPT coding underscores the fact that it is inherently incorrect for carriers to place restrictions on the number,
type, or order of diagnoses associated with the reporting of 2 visits on the same day.
There are also some carriers that, through failure to recognize all services provided during a single patient
session, potentially increase the number of visits necessary to address a patient’s concerns. If a patient is
seen for a preventive medicine visit and the physician discovers that the patient has symptoms of otitis media
during the examination, clinical protocol and common sense would dictate that the physician take care of the
well-child examination and the treatment of the otitis media during that single patient visit. Unfortunately,
the fact that some carriers fail to fairly pay the physician for providing both services will motivate providers to
address only the acute problem and have the patient/parent return at a later date for the preventive medicine
visit. This situation is frustrating for everyone involved, especially for the insureds.
While there is no legal mandate requiring private carriers to adhere to the aforementioned CPT guidelines,
it is considered a good-faith gesture for them to do so, given that the guidelines are the current standard
within organized medicine. Because providers are clearly instructed that an office/outpatient “sick” visit cannot
be reported unless it represents a significant, separately identifiable service beyond the preventive medicine
service, carriers should feel confident that the reporting of 2 visits on a single date of service will not occur
unless it is justified.
Enclosed is a copy of the original claim that was submitted with a request that you process payment as
indicated on the claim. I look forward to receiving your response.
If you have any questions, please feel free to contact me at _________________________________________.
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