Modifier 25 misuse appeal

{{your_name}} {{your_address}} {{provider_name}} Billing Department {{provider_address}} Re: Modifier 25 misuse dispute - account {{your_account}}, date of service {{visit_date}} To whom it may concern, I'm disputing the separate billing of E/M code {{em_code}} alongside procedure {{procedure_code}} for the same date of service. Modifier 25 is attached to justify the separate E/M charge. Per CMS Pub. 100-04, Chapter 12, § 30.6.6, modifier 25 may only be used when the E/M service is "significant, separately identifiable" from the procedure itself. The medical record must document a level of E/M work that is above and beyond the pre- and post-service work usually associated with the procedure. A brief discussion with the provider before the procedure does not meet this standard. I'm requesting: 1. Reversal of the {{em_amount}} {{em_code}} charge UNLESS you can furnish documentation that meets the CMS modifier-25 standard. 2. If documentation exists, a copy of the relevant medical-record excerpt so I can verify the separate E/M work. Please respond in writing within 30 days. Sincerely, {{your_name}}