Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room (99285) services provided to the enrollee 
on November 25, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 99285 is downgraded, as CPT 99284 is more appropriate. 
 
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 the billed code 99285 is "Emergency department visit for the 
evaluation and management of a patient, which requires these 3 key components within the constraints imposed 
by the urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of 
high severity and pose an immediate significant threat to life or physiologic function." 
 
The plan downgraded the coding to CPT 99284, which has a definition of "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." 
 
We asked our 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 use CPT 99285 to represent the denied services. Our reviewer 
says that the services at issue in this case were not supported by the medical records. Our reviewer found that 
the patient presented with complaints of burning with urination and discharge from penis. He had a suprapubic 
tube in place which was last changed about one month prior. He has no fever, no nausea, no vomiting, no 
inability to tolerate oral intake. Vitals included blood pressure 148/79, pulse 83, respirations 18 and 
temperature 98.7. There was suprapubic tenderness without guarding and tenderness of testicles and perineum. 
White blood cell count was 7900 and urinalysis was consistent with urinary tract infection. He was diagnosed 
with a urinary tract infection and discharged with oral antibiotic. The decision-making in this case was 
considered to be of moderate complexity and more in line with CPT 99284, rather than CPT 99285. This was 
because the presenting problems did not pose an immediate significant threat to life or physiologic function. 
 
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for emergency room (99285) services provided to the enrollee on November 25, 2021.