Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) and subsequent hospital care 
(99233) provided from March 19, 2022, through March 22, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 the services. Our reviewer found the documentation indicates 
that procedure code 99223 (1 Unit) was not supported. This initial hospital care evaluation and management 
code requires a comprehensive history, a comprehensive examination and medical decision making of high 
complexity. However, the medical records submitted did not support a comprehensive history. Procedure code 
99233 (1 Unit) was 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. However, the medical records submitted did not support a detailed interval history 
and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (99223) and subsequent hospital care (99233) provided from March 19, 
2022, through March 22, 2022.