Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99307 and 99308 rendered on September 1, 2021. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says that the records do not support the services billed. 
 
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 
the denied codes is: 
 
CPT 99307: 
 
Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at 
least 2 of these 3 key components: A problem focused interval history; A problem focused examination; 
Straightforward medical decision making. 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 stable, recovering, or improving. Typically, 10 
minutes are spent at the bedside and on the patient's facility floor or unit 
 
CPT 99308: 
 
Subsequent nursing facility 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 low 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, 15 minutes are spent at the bedside and on the 
patient's facility 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 says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation does support that 
subsequent nursing facility evaluation and management services were rendered in this case with an expanded 
problem focused interval history, an expanded problem focused examination, and medical decision making that 
was straight forward. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 99307 and 99308 rendered on September 1, 2021.  
 
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.