Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay forCPT code 99406. We decided that the Plan does not have to pay forCPT codes 99223 and 99232. You asked the Plan to pay forCPT codes 99406, 99223 and 99232. You say that you would like the Plan to reconsider their denial of payment.The Plan says that the services are not covered.We decided that the Planhas to pay forCPT code 99406. The Plan must followMedicare 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 99406 is Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes.We find that CPT code 99406 is supported in the medical record. In this case, the medical records provided show that 3 to 5 minutes were spent counseling the enrollee, including modalities to assist this such as a nicotine patch. Based on this information, we decided that Medicare rules for coverage of CPT code 99406 have been met. Therefore, we decided that the Plan has to pay forCPT code 99406. We also decided that the Plandoes not have topay forCPT codes 99223 and 99232.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 99223 is Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.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 ofthese 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 thebedside and on the patient's hospital floor or unit.We find that CPT codes 99223 and 99232 are not supported in the medical record. CPT codes 99223 and 99232 are time-based codes. In order to bill CPT code 99223, the documentation must note at least 70 minutes were spent providing this service to the enrollee. The progress note for May 26, 2020 does not note how much time was spent providing this service to the enrollee. In order to bill CPT code 99232, the documentation must note at least 25 minutes were spent providing this service to the enrollee. The progress note for May 27, 2020 does not note how much time was spent providing this service to the enrollee.As such, the provided documentation does not support the billing of CPT codes 99223 and 99232. Therefore, we decided that the Plan does not have to pay forCPT codes 99223 and 99232.