Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for procedure codes 93653, 93613, 93623, and 93621. We decided that the Plan does not have to pay for procedure code 99222.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan says that procedure codes 93653, 93613, 93623, 93621, and 99222 are not supported.

We decided that the Plan has to pay for procedure codes 93653, 93613, 93623, and 93621.

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 93653 is comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, with attempted induction of arrhythmia, with right atrial pacing and recording, with treatment of supraventricular tachycardia by ablation. The definition of code 93613 is intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure). The definition of code 96323 is programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure). The definition of code 93621 is comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, with attempted induction of arrhythmia, with left atrial pacing and recording from coronary sinus. 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 these services. Our reviewer says that the submitted records support the billing of codes 93653, 93613, 93623, and 93621 and do not support the billing of code 99222. Our reviewer found the documentation shows that the enrollee was admitted on April 10, 2021 and discharged on April 14, 2021; therefore, an initial hospital care evaluation and management code is an inappropriate code to report. A more appropriate code should be reported with a subsequent hospital care code. The submitted records include a procedure report documenting that codes 93653, 93613, 93623, and 93621 were performed on date of service April 13, 2021. The billing of these codes 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 codes 93653, 93613, 93623, and 93621 billed on April 13, 2021.

We also decided that the Plan does not have to pay for procedure code 99222.

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 99222 is Level 2 initial hospital care for evaluation and management of patient with problem of moderate severity, including comprehensive history and physical examination, and medical decision-making of moderate complexity, typical time 50 minutes.

We looked at this coder's review, the file, and Medicare rules. The coder review states that code 99222 is not supported. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan does not have to pay for procedure code 99222 billed on April 12, 2021.