Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided form January 22, 2022, 
to January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
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 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 the services. Our reviewer says that the use of codes 99223 
and 99233 is not supported by the records provided. Our reviewer found that for code 99223, medical decision 
making of high complexity requires an extensive number of diagnoses, an extensive amount and complexity of 
data and high risk of complications; two acute problems are documented in this case - hyponatremia and a fecal 
impaction. The treatment plan is intravenous fluids, consultations with specialists and an unspecified treatment 
for the impaction. This assessment does not meet criteria for an extensive number of acute diagnoses, an 
extensive amount and complexity of data and high risk of complications. For code 99233 on January 23, 2022, 
medical decision making of high complexity is not supported with a plan of continuing intravenous fluids and 
"all current care" and levothyroxine dose adjustment. For code 99233 on January 24, 2022, medical decision 
making of high complexity is not supported with a plan of "continue the patient on current care" and increase 
physical activity. 
 
We looked at this coder's 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 the services (99223, 99233) provided form January 22, 2022, to January 24, 2022.