Appeal type: ER
Decision: Partially Favorable

We decided that the Plan has to pay for code 99284. We decided that the Plan does not have to pay for code 99285.
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 99285 and they will pay to down code the services to 99283.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status): 1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for code 99285 Our reviewer says that the medical records do not support the billing of code 99285. Our reviewer found the emergency room report documents a Comprehensive History and Comprehensive Exam. However, documentation supports Medical Decision Making of moderate complexity with review and/or order of clinical lab tests and review and/or order of tests in the medicine section, therefore documentation supports level CPT 99284. Per CPT guidelines for emergency room visit which requires 3 of 3 key components of evaluation and management. In this case, CPT 99285 would not be covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit represented by code 99285 provided on December 12, 2020.
We also decided that the Plan must pay code 99284, as this code is supported by the medical records provided.
The definition of code 99284 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.