Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service March 27, 2022, to 
March 31, 2022, and code 99232 for dates of service April 1, 2022, April 4, 2022, and April 5, 2022. 
 
You asked the Plan to pay for codes 99233 and 99232. You say that the medical records support the services as 
billed. The Plan denied your request. The Plan says code 99233 billed for dates of service March 27, 2022, to 
March 31, 2022, is not supported in the medical record. For these dates, the exams were limited to ocular and 
vital signs; labs reviewed, with straight-forward decision-making to confer with physical therapy and "await 
improvement." Documentation supports only 99231. Code 99232 billed for date of service April 1, 2022, is not 
supported. The record was only 5 lines of documentation and only supported a problem-focused exam with 
low-level decision making. The documentation for this date supported code 99231. For dates of service April 4, 
2022, and April 5, 2022, code 99232 is not supported, but code 99231 is supported. The records show a limited, 
problem-focused exam, no history, with labs reviewed and ordered for low-level decision-making. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination 
of care with other providers or agencies are provided consistent with the nature of the problem(s) and the 
patients and/or familys needs. Usually, the patient is unstable or has developed a significant complication or a 
significant new problem. Physicians typically spend 35 minutes at the bedside and on the patients hospital 
floor or unit. The definition of code 99232 is subsequent hospital care, per day, for the evaluation and 
management of a patient, which requires at least 2 of the 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 providers or agencies are provided consistent with the nature 
of the problem(s) and the patients and/or familys needs. Usually, the patient is responding inadequately to 
therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on 
the patients 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 99233 and 99232. Our reviewer says that the 
documentation does not support the billing of code 99233 for dates of service March 27, 2022, to March 31, 
2022, and code 99232 for dates of service April 1, 2022, April 4, 2022, and April 5, 2022. Our reviewer found 
the enrollee was a then, 68 year-old male admitted with a gastrointestinal bleed. Per the documentation for 
March 27, 2022, to March 31, 2022, the medical records show the exams were limited with straight-forward 
decision-making. For dates of service of April 1, 2022, April 4, 2022, and April 5, 2022, there were only 5 lines 
of documentation, which support only a problem focused exam with low-level decision-making. These services 
were limited exams with no history. 
 
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 99233 and 99232 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99233 billed for dates of service March 27, 2022, to March 31, 2022, and code 
99232 for dates of service April 1, 2022, April 4, 2022, and April 5, 2022.