Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99497-25. We decided that the Plan does not have to pay for 99239.  
 
You asked the Plan to pay for practitioner services provided on February 21, 2023, to May 17, 2023, billed 
with procedure codes 99239 and 99497-25. You say that the claim is billed correctly and should be paid. The 
Plan says that documentation does not support the billed codes. 
 We decided that the Plan has to pay for 99497-25.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding 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 item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our physician reviewer found that the procedure report 
does not include documentation to support per CPT code description "more than 30 minutes". Therefore, code 
99239 cannot be verified. The procedure report documents: "goal of care; spent an hour speaking to patient and 
wife regarding goals of care. He is do-not-resuscitate, do not intubate doesn't want percutaneous endoscopic 
gastrostomy (PEG), wants to be comfortable, doesn't want to prolong-his-suffering; would refer to home 
hospice, patient refusing inpatient hospice". Therefore, procedure report supports advanced care planning with 
patient and wife for an hour.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 99497-25.  
 
We also decided that the Plan does not have to pay for 99239. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding 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 item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our physician reviewer found that the procedure report 
does not include documentation to support per CPT code description "more than 30 minutes". Therefore, code 
99239 cannot be verified. The procedure report documents: "goal of care; spent an hour speaking to patient and 
wife regarding goals of care. He is do-not-resuscitate (DNR), do not intubate (DNI), doesn't want percutaneous 
endoscopic gastrostomy (PEG), wants to be comfortable, doesn't want to prolong-his-suffering; would refer to 
home hospice, patient refusing inpatient hospice". Therefore, procedure report supports advanced care planning 
with patient and wife for an hour.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 99239. 
 
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.