Explanation and Template for Appealing E/M Denials

 As communicated in previous emails from the OSCA, some insurance companies have started denying E/M codes, specifically re-exam codes.  Some insurance companies have been more forthcoming than others regarding their policy on re-examination (E/M services).  Discussions between OSCA and Anthem early this summer created better insight into Anthem’s policy.  Their criteria for denial of re-examination was explained as the following:

• Within 60 days of another exam
• With the same or similar diagnosis
• When performed with a treatment on the same visit

The OSCA used this as an educational opportunity with Anthem to explain why, as a patient moves through the phases of condition-based or active care, a re-exam would be a reasonable and appropriate service to render, even though it would trigger a denial for being within 60 days of another exam, with the same or similar diagnosis, and/or performed on the same day as another treatment.

It was a productive conversation and the Anthem representatives acknowledged a better understanding of how a re-exam may be used in the course of chiropractic treatment.  

As such, if you have performed a re-examination on a patient and experienced a denial of payment and feel that your E/M service meets the criteria for separate reimbursement, the attached appeal letter can be customized to your office and used to request an appeal of the denied service. (Remember, this is a sample template.  You must customize it to the specific and relevant details of  your office/patient case)

You must send documentation to support your appeal.  Additionally, always ensure that all services, and in this case re-examinations (E/M) that you perform meet the criteria necessary for the cpt code you have selected.

Once your appeal has been considered, please follow up with Dr. Spaulding at the OSCA regarding the outcome of your appeal. 

Sample Appeal Letter