Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the outpatient office visit. We decided that the Plan does not have to 
pay for the transthoracic echocardiography.  
 
You asked the Plan to pay for outpatient office visit (99204) and transthoracic echocardiography (93306) 
provided April 19, 2023. You say that the medical records provided support the necessity of the services in 
dispute. The Plan says that the documents do not support services billed. 
 
We decided that the Plan has to pay for the outpatient office visit.  
 
We also decided that the Plan does not have to pay for the transthoracic echocardiography.  
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these three 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 presenting 
problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient 
and/or family. 
 
The CPT Code Manual definition of code 93306 is echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed. 
 
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 diagnostic office visit. Our reviewer says that the records 
show that the records partially support the billed services. Our reviewer found 99204 is supported. The record 
states that the enrollee presented with an undiagnosed new problem with uncertain prognosis, which indicates a 
moderate problem. The risk and patient management included medication management, which is moderate. 
This meets moderate complexity in 2 of 3 categories and supports moderate medical decision making. Time 
was not documented, therefore total time spent was not considered. 93306 is not supported. The record does 
not contain evidence that a complete transthoracic echocardiogram was performed during this encounter.  
 
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 diagnostic office visit have been met and the Medicare rules for coverage of 
the diagnostic office visit have not been met. Therefore, we decided that the Plan has to pay for the outpatient 
office visit and the Plan does not have to pay for the transthoracic echocardiography. 
 
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.