TO: , Medical Director FROM: DATE: I am writing to request your assistance in correcting problems my office has experienced with inappropriate bundling of separate services and denial of fair reimbursement by (name of insurance company). My specific concern relates to the failure of your carrier to recognize the AMA/CPT Modifier "-25" which designates a separately identifiable evaluation and management service performed on the same date as another procedure. The enclosed explanations of benefit statements are examples of such inappropriate claims processing. The American Medical Association has clearly identified such bundling as abusive, since it ignores the intent of modifier -25, which should prevent inappropriate bundling of separate services. The services to my patients that were erroneously bundled in your claims processing were an evaluation and management service and a skin biopsy procedure (or insert name of other bundled procedure). An evaluation and management service requires the performance and documentation of the history, the examination, and the medical decision making appropriate for the level of service described by the code. The physician work involved is reflected in the RBRVS value, e.g. CPT code 99202 for an initial office visit has a total RVU of 1.70. There is no part of these three physician components of the E/M service that involves a separate surgical procedure, such as a skin biopsy. The skin biopsy procedure, CPT 11100, include the pre-service, intra-service and post-service work, related only to the performance of this procedure, and it does not include any of the components of the E/M service. The skin biopsy procedure has a total RVU of 2.09 for 2003. Both of these services have defined components of the work involved, upon which their individual values have been established. The physician work involved in the provision of these two procedures is no different, whether these separate services are provided on the same date or on different dates. It is well accepted that when the services are performed on different dates, all carriers routinely allow payment for each of the separate services. Unfortunately, your claims processing software has failed to recognize that it is just as appropriate to pay for both services when they are performed on the same date. When two such services are provided on the same date, and in which there is no overlap in the components of their physician work, there can be no justification for bundling such services together as if only one service were provided. Letter to Medical Director Page Two In the course of skin examinations, dermatologists often discover suspicious lesions that warrant a skin biopsy. When it is possible to perform a medically necessary skin biopsy on your subscribers on the same date of service, we prefer to do so for their convenience and to facilitate a prompt diagnosis. We would rather not have to tell your subscribers that they must return at a subsequent date for their skin biopsy, just to prevent inappropriate bundling by their insurance carrier. Would you please review your company's claim processing to insure that it properly recognizes the "- 25" modifier, and that any code edits are consistent with the AMA/CPT coding system? I would appreciate your assistance, as well, in directing your claims review staff to reprocess the enclosed claims in light of the above information, so that appropriate payment can be made. Thank you in advance for your cooperation. Sincerely, PHYSICIAN WORK ASSOCIATED WITH SKIN BIOPSY PROCEDURES (e.g. CPT CODES 11100 OR 11101) Skin biopsy procedures are frequently needed to confirm the nature of a presenting clinical problem. In other instances, suspicious lesions are encountered in the course of a skin examination, which may be unrelated to the presenting problem. In either case, the physician work involved for these procedures is separate from the evaluation and management services. The physician pre-service work will include: discussion of the probable diagnoses and indication for the biopsy procedure, risks, and benefits; description of the biopsy procedure method, and expected result or scar. In addition, a patient agreement/informed consent must be obtained and staff must be advised for preparation of patient and necessary anesthetic, supplies, and instrument tray preparation. The intra-service work can include: inspection and palpation of the lesion to assess depth and to select the most representative lesion or site to obtain the specimen; cleansing of the biopsy site with suitable antiseptic; injection of appropriate local anesthetic; scrubbing and gloving by physician; application of sterile drape; obtain skin specimen with scalpel, skin punch or suitable instrument, depending on depth and amount of tissue needed; collection of specimen in labeled container; undermine wound edges as needed to facilitate repair; suture as necessary to approximate wound edges or achieve hemostasis with pressure, chemical or electrocautery, or application of topical hemostatic agents, e.g. Gelfoam or Surgicel; application of Steri-Strips or antibiotic ointment and sterile dressing. The post-service work can include: instruction of the patient and/or family on postoperative wound care, dressing changes, and follow-up; patient advised how to recognize significant complication, e.g. bleeding, or allergic reaction to antibiotic ointment or adhesive dressing; patient advised when results will be available and how they will be communicated; completion of medical records; and communication of results to referring physician as appropriate.