Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99223 and 99233 provided from March 1, 2022, to 
March 2, 2022. 
 
You asked the Plan to pay for codes 99223 and 99233. 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 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 physician reviewer 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 99223 and 99233. Our reviewer says 
that the documentation does not support the codes billed. Our reviewer found the enrollee presented to the 
emergency department on March 1, 2022 status post fall with dizziness. The evaluation revealed a left basal 
ganglia ischemic cerebral vascular accident (CVA). 
 
The reviewed documentation indicates that CPT code 99223-Al was not supported. This initial hospital care 
evaluation and management code requires a comprehensive history, a comprehensive examination and medical 
decision making of high complexity. However, the medical records submitted did not support a comprehensive 
history, a comprehensive examination and medical decision making of high complexity. 
 
CPT code 99233 was not supported. This subsequent hospital care evaluation and management code requires 
two out of these three key components: a detailed interval history, a detailed examination and medical decision 
making of high complexity. However, the medical records submitted did not support a detailed interval history, 
a detailed examination and medical decision making of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99223 and 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 99223 and 99233 provided from March 1, 2022, to March 2, 2022.