Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial and subsequent hospital care (99223 and 99233) 
provided from May 28, 2022, through May 31, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 and 99233 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 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 found the documentation indicates 
that for the dates of service May 30, 2022, and May 31, 2022, code 99223 FS (1 unit) was not supported. The 
evaluation and management code billed requires a medically appropriate history and/or examination and high 
level of medical decision making. In this case, the medical records submitted did support a decision making of 
high complexity. For the dates of services May 28, 2022, and May 29, 2022, the documentation indicates that 
code 99233 (1 unit) was not supported. The evaluation and management code billed requires a detailed interval 
history, a detailed examination and medical decision making of high complexity. In this case, the medical 
records submitted don't support an interval history and medical decision making of high complexity. 
 
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 initial and subsequent hospital care (99223 and 99233) provided from May 28, 2022, 
through May 31, 2022.