Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service December 23, 2022, 
and code 99233 billed for dates of service December 24, 2022, and December 25, 2022. 
 
You asked the Plan to pay for codes 99223 and 99233. You say that medical records have been provided to 
support payment. The Plan denied your request. The Plan says code 99223 for date of service December 23, 
2022, is not supported by the medical record. The medical records don't support a comprehensive history and 
medical decision making of high complexity. Code 99233 billed for dates of service December 24, 2022, and 
December 25, 2022, is also not supported by the medical record. The records don't support a detailed interval 
history and medical decision making of high complexity. 
 
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 three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high complexity.  The CPT Code Manual definition of 
code 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which 
requires at least 2 of the 3 key components: A detailed interval history; A detailed examination; Medical 
decision making of high complexity. Counseling and/or coordination of care with other providers or agencies 
are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the 
patient is unstable or has developed a significant complication or a significant new problem. Physicians 
typically spend 35 minutes at the bedside and on the patients 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 to pay for codes 99223 and 99233. Our reviewer says that codes 99223 
and 99233 are not supported by the medical record. Our reviewer found the enrollee with a history of 
amyotrophic lateral sclerosis presented to the emergency room with complaints of weakness. For code 99223 
for date of service December 23, 2022, the documentation supports a comprehensive exam, but not a 
comprehensive history or medical decision making of high complexity. As a result, this code is not supported.  
For code 99233 for dates of service of December 24, 2023, and December 25, 2023, the documentation 
supports an appropriate exam, but not an appropriate history or medical decision making of high level. As a 
result, code 99233 is not supported on either billed date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99223 and 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99223 billed for date of service December 23, 2022, and code 99233 billed for 
dates of service December 24, 2022, and December 25, 2022.