Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided from February 1, 2021 to February 5, 2021.
You asked the Plan to pay for 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. (99233). You say that all daily visits were medically necessary to evaluate and
treat the enrollee. The Plan denied your request. The Plan says documentation submitted does not support the services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
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 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. (99233). Our reviewer says that the services do not meet criteria for reimbursement. Our reviewer found February 1, 2021 - (documentation starting on page 28) Provider documented "Did not enter the patients room - Covid 19 positive). As there was no Review of Systems (ROS) and exam performed, it is inappropriate to bill an evaluation and management code. February 1, 2021 09:26:55 (documentation starting on page 32) documentation supports a problem focused history (3 conditions, no ROS, Past, Family and/or Social History (PFSH) Complete) expanded problem focused exam ( 7 systems reviewed); and medical decision making of complexity. Per 95 guidelines for E and M coding, service documented supports level 99232. February 2, 2021 - (documentation starting on page 50) documentation includes an operative note. CPT 99233 is an inappropriate code to report for this service, as there is no documentation to support this code. February 3, 2021 - no documentation found to support this code in documentation submitted submitted for this date of service. February 4, 2021 - no documentation found to support this code in documentation submitted for this date of service February 5, 2021 - no documentation found to support this code in documentation submitted 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 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. (99233) have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided from February 1, 2021 to February 5, 2021.