Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the cardiology evaluation provided in the hospital observation setting on June 25, 2020, billed with code 99204 and the inpatient cardiology evaluation provided on June 26, 2020, billed with code 99232.
You asked the Plan to pay for the two cardiology evaluations. You say that the billed codes are correct since the enrollee was still in observation status on June 25 and was admitted to inpatient status on the date of discharge on June 26. The Plan denied your request. The Plan says that procedure code 99239 has an unbundled relationship with the procedure code 99232. Since procedure code 99239 was billed on the same date, 99232 is not payable even if there were a modifier. In addition, a modifier would be required for payment of 99204.
The Plan must follow Medicare rules. Medicare rules say that for an enrollee in observation status, only the provider who admitted to observation can be paid the observation codes. All other providers evaluating the patient during the observation stay use the appropriate outpatient codes. In addition, only the attending physician can bill code 99239, all other consultants use a code from the 99231-99233 range to report their final visit with the patient for the hospital stay. In this case, the Plan failed to provide any proof of which other codes were paid on this date of service and to which physicians payment has been made. Maximus can only base our decision on the information we have available in the file. Since the patient was reportedly still an outpatient on June 25, 2020, and the physician at issue in this case furnished a cardiology evaluation, the use of code 99204 would be correct, as this is an appropriate outpatient service code. There is no need for a modifier as there is no evidence that this physician or another cardiologist from the same group practice billed any other evaluation services on this date. Likewise, the Plan has indicated (without evidence) that the code 99239 was billed on June 26, 2021. However, the Plan did not show that this code was billed by this physician or another cardiologist from the same group practice. As this provider was responsible only for the patient's cardiology care, it would be expected that
he/she was not the attending hospitalist who would bill the 99239 code. Use of code 99232 without any modifier is appropriate to reflect the final visit rendered during a hospital stay by the consulting cardiologist. The Plan has not provided any cogent denial rationale supported by evidence to justify the denial of payment for these services. Therefore, we decided that the Plan has to pay for the cardiology evaluation provided in the hospital observation setting on June 25, 2020, billed with code 99204 and the inpatient cardiology evaluation provided on June 26, 2020, billed with code 99232.
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.