Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services (procedure codes 99220 and 99232) provided to the enrollee from July 22, 2021, to August 6, 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 this was not coded correctly.  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 denied codes is:  CPT 99220:  Initial observation 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 to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit  CPT 99232:  Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 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 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 services at issue in this case were not supported by the medical records. Our reviewer found in terms of CPT 99232, the documentation supports CPT 99232 was billed for date of service July 22, 2021 with claim number AJXZR4W643 (payment number 147492), and CPT 99233 for date of service July 22, 2021 claim number is blacked out, however payment number is 136956.  This code set would be covered once per date, any other consultations or patient visits should be reported with outpatient code. For CPT 99220, the documentation supports this code was billed twice for date of service August 6, 2021. The documentation shows claim number AJXYHWJ7YZ and AJX3A34CC5. These denied services were reported incorrectly and therefore, not covered.   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 hospital services (procedure codes 99220 and 99232) provided to the enrollee from July 22, 2021, to August 6, 2021.