Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99219, 99224 and 99225 rendered from July 
7, 2022, to July 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 99219: 
 
Initial observation 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 
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 problem(s) requiring admission to outpatient hospital "observation status" are of 
moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99224: 
 
Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 
of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision 
making that is straightforward or of low 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 stable, recovering, or improving. 
Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99224: 
 
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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 99219, the 
procedure report for this date of service does not support the level of care billed. There is only a detailed 
history. There is no documentation to support the observation level of care. In terms of CPT 99224, the 
procedure report for this date of service does not support level billed, as medical record does not include 
documentation to support observation care.  Finally, in terms of CPT 99225, there is no documentation of an 
observation level of care, and the documentation does not support an expanded problem-focused interval 
history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99219, 99224 and 99225 rendered from July 7, 2022, to July 9, 2022.