Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99233. We decided that the Plan does not have to pay 
for procedure code 99223.  
 
You asked the Plan to pay for procedure codes 99223 and 99233 billed for May 4, 2022, to May 5, 2022. You 
say that you disagree with the denial. The Plan says that procedure codes 99223 and 99233 are not supported. 
 
We decided that the Plan has to pay for procedure code 99233.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 physician to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request for procedure code 99233. Our reviewer says that procedure code 
99233 is supported by the submitted records. Our reviewer found that the submitted records document a 
detailed interval history and a detailed examination. While medical decision making of high complexity is not 
supported, two out of the three required elements are supported by the records; therefore, code 99233 billed for 
May 5, 2022 is 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 these services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99233 billed for May 5, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 99223. 
 
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. 
 
We asked our physician to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request for procedure code 99223. Our reviewer says that procedure code 
99223 is supported by the submitted records. Our reviewer found that the submitted records document a 
detailed interval history and a detailed examination. While medical decision making of high complexity is not 
supported, two out of the three required elements are supported by the records; therefore, code 99233 billed for 
May 5, 2022 is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for May 4, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.