Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided from December 23, 2020,
to December 25, 2020.

You asked the Plan to pay for subsequent hospital care at the Current Procedural Terminology (CPT) code
99233 level. You say that medical records support payment at a CPT 99233 level. The Plan denied your
request. The Plan says the records support a CPT 99232 level of payment; 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.

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 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 coder 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 subsequent hospital care at the Current Procedural
Terminology (CPT) code 99233 level. Our reviewer says that the documentation submitted was reviewed and
does not meet criteria. Our reviewer found documentation submitted for December 23, 2020 was reviewed and
does not meet criteria - documentation does not support CPT 99233 - a comprehensive history and exam was
performed, and medical decision making of moderate complexity. Therefore, CPT 99232 should be reported
for this service. Documentation submitted for December 24, 2020 and December 25, 2020 for CPT 99233 is
not supported. Documentation for both dates of service include problem focused history and exams, with
straightforward medical decision making. Therefore, CPT 99231 should be reported for this service.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of subsequent hospital care at the Current Procedural Terminology (CPT) code
99233 level have not been met. Therefore, we decided that the Plan does not have to pay at the code 99233
level for subsequent hospital care provided from December 23, 2020, to December 25, 2020.