Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99217. We decided that the Plan does not have to pay 
for procedure code 99225 
 
You asked the Plan to pay for procedure codes 99225 and 99217 billed for May 12, 2022, to May 13, 2022. 
You say that you disagree with the denial. The Plan says that procedure codes 99225 and 99217 are not 
supported. 
 We decided that the Plan has to pay for procedure code 99217. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]). 
 
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 for these services. Our reviewer says that procedure code 99217 is 
supported by the medical records. Our reviewer found that code 99217 requires a final examination of the 
patient, discussion of the hospital stay, instructions for continuing care and preparation of discharge records. 
The submitted records include a final examination of the patient, discussion of the hospital stay, instructions for 
continuing care, and preparation of discharge records. Code 99217 is therefore supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99217 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99217 billed for May 13, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 99225. 
 
In this case, the CPT Code Manual definition of code 99225 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 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 for these services. Our reviewer says that procedure code 99225 is not 
supported by the medical records. Our reviewer found that an expanded, problem-focused interval history 
requires a chief complaint, a brief history of present illness and a problem pertinent review of systems. The 
provided records in this case do not document a chief complaint, a brief history of present illness and a problem 
pertinent review of systems. An expanded problem focused examination requires a limited examination of the 
affected body area or organ system and other symptomatic or related systems. The provided records in this case 
do not document a limited examination of the affected body area or organ system and other symptomatic or 
related systems. Medical decision making of moderate complexity requires 2 out of 3 of multiple diagnoses or 
management options, a moderate amount and complexity of data reviewed and moderate risk of complication.  
The provided records in this case do not document 2 out of 3 of multiple diagnoses or management options, a 
moderate amount and complexity of data reviewed and moderate risk of complication. The records do not 
support code 99225. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99225 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99225 billed for May 12, 2022. 
 
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.