CO-4 Modifier Appeal Letter

[PRACTICE_NAME] [PRACTICE_ADDRESS] [PRACTICE_CITY_STATE_ZIP] [PRACTICE_PHONE] [PRACTICE_FAX] NPI: [RENDERING_PROVIDER_NPI] Tax ID: [PRACTICE_TAX_ID] [DATE] [PAYER_NAME] [PAYER_APPEALS_DEPARTMENT] [PAYER_ADDRESS] [PAYER_CITY_STATE_ZIP] Re: Appeal of Claim Denial -- CARC CO-4 (Procedure Code Inconsistent with Modifier Used) Patient Name: [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME] Member ID: [MEMBER_ID] Date of Service: [DATE_OF_SERVICE] Claim Number: [CLAIM_NUMBER] Procedure Code: [CPT_CODE] Modifier(s) Reported: [MODIFIERS_REPORTED] Dear Appeals Review Committee: I am writing to appeal the denial of the above-referenced claim under CARC CO-4. The denial indicates that the procedure code is inconsistent with the modifier(s) used. We respectfully submit that the modifier(s) reported on this claim were correctly applied based on the documented clinical circumstances and the applicable NCCI policy. CLINICAL RATIONALE FOR MODIFIER: Modifier [MODIFIER_CODE] was appended to procedure [CPT_CODE] to indicate [MODIFIER_CLINICAL_REASON]. Specifically, on [DATE_OF_SERVICE], [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME] underwent [PROCEDURE_DESCRIPTION] in conjunction with [SECOND_PROCEDURE_OR_CIRCUMSTANCE]. The treating provider documented [SPECIFIC_DOCUMENTATION_QUOTE] supporting that the services were [DISTINCT_SEPARATE_OR_BILATERAL_AS_APPLICABLE]. NCCI POLICY SUPPORT: Per the CMS NCCI Policy Manual, Chapter [CHAPTER_NUMBER], Section [SECTION_NUMBER], modifier [MODIFIER_CODE] is appropriate when [CITED_NCCI_GUIDANCE]. The code pair [PRIMARY_CPT] / [SECONDARY_CPT] permits modifier override when documentation supports the clinical distinction described above. We have enclosed the relevant excerpt from the NCCI Policy Manual along with the operative or procedure note that demonstrates the supporting documentation. CORRECTED CLAIM (IF APPLICABLE): [USE THIS PARAGRAPH ONLY IF SUBMITTING A CORRECTED CLAIM] Upon review, we have determined that modifier [ORIGINAL_MODIFIER] was reported in error. The clinically appropriate modifier is [CORRECTED_MODIFIER], which we have applied to the enclosed corrected claim. We respectfully request that the payer process the corrected claim under frequency code 7 and re-adjudicate accordingly. ENCLOSED DOCUMENTATION: 1. Operative or procedure note from [DATE_OF_SERVICE] 2. NCCI Policy Manual excerpt: Chapter [CHAPTER_NUMBER], Section [SECTION_NUMBER] 3. Clinical documentation supporting modifier application 4. Corrected claim form (if applicable) 5. Original Explanation of Benefits dated [EOB_DATE] This appeal is submitted within the [APPEAL_DEADLINE_DAYS]-day filing window from the EOB date. We respectfully request re-adjudication of the original claim or, if a corrected claim was enclosed, processing of the corrected submission. If the Appeals Review Committee determines that clinical review is warranted, we are available for peer-to-peer discussion at [PRACTICE_PHONE]. Respectfully, [PROVIDER_NAME], [PROVIDER_CREDENTIALS] [PROVIDER_TITLE] NPI: [RENDERING_PROVIDER_NPI] Enclosures: [NUMBER_OF_ENCLOSURES] cc: Patient file