Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99225. We decided that the Plan does not have to pay for 99497.  
 
You asked the Plan to pay for hospital services (procedure codes 99225 and 99497) provided to the enrollee 
from August 19, 2021, to August 31, 2021.. You say that this should be paid for. The Plan says that the records 
do not support the services billed. 
 
We decided that the Plan has to pay for 99225.  
 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 99225 is "Subsequent observation 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 physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 99225. Our reviewer says that the medical 
records support the use of procedure code 99225 based on the plan of care in the service notes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
99225.  
 
We also decided that the Plan does not have to pay for 99497. 
 
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 99497 is "Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate." 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 99497. Our reviewer says that the medical 
records do not support the use of CPT 99497 in this case. The use of advanced care planning for these dates of 
service does not meet the requirements to be billed separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99497 have not been met. Therefore, we decided that the Plan does not have to 
pay for 99497. 
 
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.