Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care services, initial (99223) and subsequent 
(99233), billed for dates of service from April 25, 2022, to April 29, 2022. 
 
You asked the Plan to pay for hospital care services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the provided 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 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 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 hospital care services. Our reviewer says that CPT codes 
99223 and 99233 do not meet criteria for payment. Our reviewer found CPT code 99223 is not supported. This 
initial hospital care evaluation and management code requires a comprehensive history, a comprehensive 
examination and medical decision making of high complexity. In this case, there was a comprehensive history 
and a comprehensive exam; however, the medical records submitted did not support a medical decision making 
of high complexity. CPT code 99233 is not supported. This subsequent hospital care evaluation and 
management code requires two out of these three key components: a detailed interval history, a detailed 
examination and medical decision making of high complexity. In this case, there was a detailed examination; 
however, the medical records submitted did not support a detailed interval history or medical decision making 
of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hospital care services have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital care services, initial (99223) and subsequent (99233), billed for dates of 
service from April 25, 2022, to April 29, 2022.