Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (99443) provided to the enrollee on June
14, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information as to the origin of the service. The Plan shows the
guidelines for codes 9944199443 state: "Telephone services are nonfaceto face evaluation and management
(E/M) services provided to a patient using the telephone by a physician or other qualified health care
professional, who may report evaluation and management services. These codes are used to report episodes of
patient care initiated by an established patient or guardian of an established patient." The documentation does
not show that the service was initiated by the enrollee. The documentation shows this was a consultation
request which came from another provider, not a service initiated by the enrollee. In addition, the description in
the guidelines for code 99443 is: " Telephone evaluation and management service by a physician or other
qualified health care professional who may report evaluation and management services provided to an
established patient, parent, or guardian not originating from a related evaluation and management (E/M)
service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24
hours or soonest available appointment; 2130 minutes of medical discussion." The documentation in this case
does not show "2130 minutes of medical discussion" to support use of this code. The documentation shows
the provider spent 6 minutes talking to the enrollee. The remaining time (31 minutes total) was spent reviewing
records and in coordination of care.
Based on this code description, telephone codes 9944199443 may be billed only for the time spent in medical
discussion with the enrollee and do not include time spent reviewing records or coordination of care. If the
documentation had shown a service initiated by the enrollee, the provider would have been justified in
reporting code 99441 based on this documentation, but not code 99443. Medicare allows codes G0425G0427
to be reported for inpatient telephone consultations, but the provider does not meet the minimum time
requirement (minimum of 15 minutes of direct patient communication) for any of those codes. This would be a
billable service only if the patient had performed the visit by twoway video, in which case an inpatient E/M
visit code could have been reported.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this was
service was not initiated by the enrollee's request and therefore was not billed appropriately based on the
Medicare billing guidelines for telehealth or telephonic services. Therefore, we decided that the Plan does not
have to pay for telehealth services (99443) provided to the enrollee on June 14, 2021.