Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for CPT
code 99232 for June 7, 2020, to June 9, 2020, and CPT code 99233 for June 5, 2020, and June 6, 2020.

You asked the Plan to pay for the services. The Plan says that the billed codes are not supported.

We decided that the Plan has to pay for CPT code 99232 for June 1, 2020, to June 3, 2020, and for CPT
code 99233 for June 3, 2020, and June 4, 2020.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99232 is "Subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded
problem focused interval history; An expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit". The
CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A
detailed examination; Medical decision making of high 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 patient is unstable or has
developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the
bedside and on the patient's hospital floor or unit."

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 the services. Our reviewer says that the use
of CPT code 99232 is supported by the records provided for June 1, 2020, to June 3, 2020. Our reviewer also
says that the use of CPT code 99233 is supported by the records provided for June 3, 2020, and June 4, 2020.
Our physician reviewer found that the medical documentation submitted meets criteria for reimbursement
consideration for CPT code 99232 for June 1, 2020 and June 2, 2020, and for CPT code 99233 for June 3,
2020, and June 4, 2020.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan has to pay
for CPT code 99232 for June 1, 2020, to June 3, 2020, and for CPT code 99233 for June 3, 2020, and June 4,
2020.

We also decided that the Plan does not have to pay for CPT code 99232 for June 7, 2020, to June 9, 2020,
and CPT code 99233 for June 5, 2020, and June 6, 2020.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of
code 99232 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which
requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded
problem focused examination; 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 patient is
responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at
the bedside and on the patient's hospital floor or unit". The CPT Code Manual definition of code 99233 is
"Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high
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 patient is unstable or has developed a significant complication or a significant new
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit."

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 the services. Our reviewer says that the use
of CPT code 99232 is not supported by the records provided for June 7, 2020, to June 9, 2020. Our reviewer
also says that the use of CPT code 99233 is not supported by the records provided for June 5, 2020, and June 6,
2020. Our physician reviewer found that the documentation does not include sufficient documentation to
support 99233 being performed on June 5, 2020, or June 6, 2020, therefore this service cannot be verified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for CPT code 99232 for June 7, 2020, to June 9, 2020, and CPT code 99233 for June 5, 2020, and
June 6, 2020.

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.