Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for initial hospital-care services. We decided that the Plan does not have to 
pay for subsequent hospital-care services.  
 
You asked the Plan to pay for initial hospital-care services (99223) and subsequent hospital-care services 
(99233) billed for dates of service from March 7, 2022, to March 8, 2022.. You say that the services at issue 
have been billed correctly. The Plan says that rules for payment have not been met. 
 
  We decided that the Plan has to pay for initial hospital-care 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. 
 
In this case, the CPT Code Manual definition of code 99223 is: 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 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 initial hospital-care services. Our reviewer says that CPT 
code 99223 meets criteria for payment. Our reviewer found that the record contains a comprehensive history, 
comprehensive exam, and medical decision making (MDM) of high complexity. The MDM included extensive 
management options, an extensive amount of data, and a high risk of morbidity/mortality. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital-care services have been met. Therefore, we decided that the Plan 
has to pay for initial hospital-care services.  
 
We also decided that the Plan does not have to pay for subsequent hospital-care 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. 
 
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 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. 
 
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 services. Our reviewer says that 
CPT code 99233 does not meet criteria for payment. Our reviewer found that the case file does not contain 
medical records for date of service March 8, 2022. It cannot be verified that the service indicated by CPT code 
99233 was provided. 
 
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 services have not been met. Therefore, we decided that 
the Plan does not have to pay for subsequent hospital-care services. 
 
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.