Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99222 and 99232 provided from August 2, 2022, to 
August 24, 2022. 
 
You asked the Plan to pay for codes 99222 and 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 99222 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 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 problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
The CPT Code Manual definition of code 99232 is 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 codes 99222 and 99232. Our reviewer says that the 
documentation does not support the codes billed. Our reviewer found the enrollee was admitted to the hospital 
for a hip injury. The documentation shows that the history and examination are not comprehensive for August 
2, 2022. The interval history is not expanded, and the medical decision making is not of moderate complexity 
for date of service August 8, 2022. The interval history is not expanded, and the medical decision making is not 
of moderate complexity for dates of service August 15, 2022 and August 22, 2022. There is no history 
regarding the new complaint of toe pain, there is no interval history regarding the ongoing leg wound, and the 
medical decision making is not of moderate complexity for date of service August 24, 2022. Therefore, the 
codes billed are not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99222 and 99232 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 99222 and 99232 provided from August 2, 2022, to August 24, 2022.