Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on October 17, 2022, October 19, 2022, and October 20, 2022, billed with codes 99223, 99233, and 
99239, respectively. 
 
You asked the Plan to pay for the EM services as billed. You say that the denied codes were billed correctly. 
The Plan denied your request. The Plan says these codes are not supported. 
 
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 definition for 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. 
 
The definition of code 99239 is Hospital discharge day management; more than 30 minutes. 
 
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 to pay for the EM services as billed. Our reviewer says 
that the codes billed for these services are not supported. Our reviewer found The billing of CPT 99223 on 
10/17/2022 is not supported, as the medical decision making was not of high complexity. The billing of CPT 
99233 on 10/18/2022 is not supported, as the interval history was not detailed, and the medical decision making 
was not of high complexity. The billing of CPT 99239 on 10/20/2022 is not supported, as the time spent 
providing discharge services is not noted. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient evaluation and management (EM) services provided on October 17, 
2022, October 19, 2022, and October 20, 2022, billed with codes 99223, 99233, and 99239, respectively.