Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92928, 93306, 99221, 99222, 99323 
rendered from October 10, 2021, to October 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 92928: 
 
Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; 
single major coronary artery or branch 
 
CPT 99306: 
 
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when 
performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography 
 CPT 99222: 
 
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 
 
CPT 99232: 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 93306, it is not 
supported. There is no procedure note for a trans-thoracic echo-cardiogram performed on this date of service. 
In terms of CPT 99323, no progress note was submitted in the case file for this date of service. This code would 
not be supported. In terms of CPT 92928, there is a procedure note for a cardiac catheterization with evaluation 
of existing stents, but no new stent placement was documented. There is a more specific code for the 
procedures performed. In terms of CPT 99222, it is not supported as no progress note was submitted in the case 
file for this date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 92928, 93306, 99221, 99222, 99323 rendered from October 10, 2021, to 
October 27, 2021.