Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99497. We decided that the Plan does not have to pay for 99220.  
 
You asked the Plan to pay for procedure codes 99220 and 99497 rendered on January 9, 2022.. 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 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 
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 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 this code is not supported by 
the medical records. The documentation states 20 minutes were spent in a discussion regarding advanced 
directives with the patient and family and the patient opted for DNR status. According to CPT coding rules, 
99497 can be reported when performed on the same date as an evaluation and management service with 
modifier 25 appended to the evaluation and management code. 
 
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 
99497.  
 
We also decided that the Plan does not have to pay for 99220. 
 
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 
99220 is "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 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 to outpatient hospital "observation status" 
are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our 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 99220. Our reviewer says that the components of CPT 
99220 are missing in the record. The medical record does not support any decision making of high complexity. 
The code is not supported.  
 
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of 99220 have not been met. Therefore, we decided that the Plan does not have to pay for 
99220. 
 
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.