Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for codes 99223 and 99291. We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 27, 2021.
You asked the Plan to pay for codes 99223 and 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan says that the medical records do not support the services billed.
We decided that the Plan has to pay for the initial hospital care represented by code 99223 provided on March 22, 2021 and the critical care services represented by code 99291 provided on March 23, 2021, March 25, 2021, and March 28, 2021.
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. The definition of code 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99223 is supported in the medical record. Specifically, the medical records for March 22, 2021 included the required 3 key components. We also find that CPT code 99291 is supported in the medical record. Specifically, the medical records for March 23, 2021, March 25, 2021, and March 28, 2021 included the first 35 minutes of evaluation and management of a critically ill patient. Based on this information, we decided that Medicare rules for coverage of codes 99223 and 99291 have been met. Therefore, we decided that the Plan has to pay for the initial hospital care represented by code 99223 provided on March 22, 2021 and the critical care services represented by code 99291 provided on March 23, 2021, March 25, 2021, and March 28, 2021.
We also decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 27, 2021.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for March 27, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291 on March 27, 2021. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on March 27, 2021.