Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99223. We decided that the Plan does not have to pay for 99232 and 
99238.  
 
You asked the Plan to pay for procedure codes 99223, 99232 and 99238 provided March 24, 2023, through 
March 28, 2023. You say that the claim should be paid. The Plan says that the services are not supported by the 
records. 
 
 
 
 
 
 We decided that the Plan has to pay for 99223.  
 
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 inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 item/service at issue. Our reviewer says that for code 
99223 provided on March 24, 2023, the documentation submitted was reviewed and does meet criteria. Three 
components for medical decision-making criteria are number and complexity of problems addressed; amount of 
data to be reviewed, and risk of complications. The procedure report documents, Problem - severe orthostatic 
hypotension and syncope; Data - Laboratory, previous echo, electrocardiogram (EKG), carotid doppler, 
computed tomography (CT), ultrasound and magnetic resonance imaging (MRI), intravenous (IV) fluids with 
IV medications, physical therapy (PT)/ occupational therapy (OT) evaluation. The procedure report in this case, 
supports an acute illness with systemic symptoms and has a high risk of morbidity without treatment. The 
documentation supports high level of medical decision making. 
 
We looked at this physician'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 99223.  
 
We also decided that the Plan does not have to pay for 99232 and 99238. 
 
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 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. The definition of code 99238- is hospital 
inpatient or observation discharge day management; 30 minutes or less on the date of the encounter. 
 
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 item/service at issue. Our reviewer says that for code 
99232 provided on March 25, 2023, the documentation submitted was reviewed and does not meet criteria. The 
procedure report supports, low with 1 acute, uncomplicated illness or injury. Therefore, low medical decision 
making is supported, which a more specific code would be reported. For code 99238 provided on March 28, 
2023, the documentation submitted was reviewed and does not meet criteria. The medical record did not 
include evaluation and management service for date of service billed. Therefore, the procedure code cannot be 
verified. 
 
We looked at this physician'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 99232 and 99238. 
 
 
 
 
 
 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.