Bundling / NCCI Edit Appeal Letter (Modifier 59)

Use this when an NCCI edit bundled a second procedure into the primary and both were genuinely separate. It wins on documentation of distinctness — separate site, session, or encounter — not on the modifier alone.

What makes it win

• Prove the two procedures were distinct: different anatomic site, separate session, or a separate encounter
• Support Modifier 59 (or the more specific X{EPSU}) with the operative/procedure note, not just the code
• Cite the NCCI Policy Manual exception that applies to the code pair
• Confirm the modifier is on the correct (secondary) line and the edit pair is separable (Modifier Indicator 1)

The template

Replace the [BRACKETED] fields with your details. This is the manual version of the appeal Volari files for you automatically.

[PRACTICE LETTERHEAD]
[DATE]

[PAYER NAME] — Appeals Department
[PAYER APPEALS ADDRESS]

RE: Appeal of Bundling / NCCI Edit Denial (CARC 97)
Patient: [PATIENT NAME]   Member ID: [MEMBER ID]
Claim #: [CLAIM NUMBER]   Date(s) of Service: [DOS]
Codes at issue: [PRIMARY CPT] and [SECONDARY CPT]

To the Appeals Department:

We are appealing the bundling of [SECONDARY CPT] into [PRIMARY CPT]. These were distinct services and [SECONDARY CPT] is separately payable with Modifier 59 (or [XS/XU/XE/XP]) appended.

The procedures were not components of one another: [DESCRIBE DISTINCTNESS — separate anatomic site / separate session / separate encounter, WITH SPECIFICS]. The NCCI edit pair carries Modifier Indicator 1, permitting a modifier when the services are separate, and the circumstances here fall within the NCCI Policy Manual exception for [CITE EXCEPTION].

The enclosed [operative/procedure] note dated [DATE] documents each service independently, including [DISTINGUISHING DETAIL: site, laterality, time, or session].

We request [SECONDARY CPT] be paid as a distinct procedural service. Please contact [CONTACT NAME] at [PHONE] with questions.

Enclosed: procedure note, corrected claim with Modifier 59 on line [LINE NUMBER].

Sincerely,
[BILLING MANAGER NAME], [TITLE]
[PRACTICE NAME] — NPI [NPI]   TIN [TIN]

Common questions

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