Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99232. We decided that the Plan does not have to pay 
for procedure codes 99233 and 99223.  
 
You asked the Plan to pay for procedure codes 99232, 99233, and 99223 billed for March 11, 2023, to March 
13, 2023.. You say that you disagree with the denial. The Plan says that the procedure codes are not covered. 
 
 We decided that the Plan has to pay for procedure code 99232. 
 
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.  
 
We asked our physician 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 procedure codes 99232, 99233, and 99223. Our reviewer 
says that procedure code 99232 is supported but codes 99233 and 99223 are not supported. Our reviewer found 
that the records support that an appropriate history and examination were performed for all codes at issue; 
however, the records do not document high complexity medical decision making for codes 99233 and 99223. 
The records support all criteria for code 99232 but do not support 99233 and 99223. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99232 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99232. 
 
We also decided that the Plan does not have to pay for procedure codes 99233 and 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 99233 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 high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. The 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 physician 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 procedure codes 99232, 99233, and 99223. Our reviewer 
says that procedure code 99232 is supported but codes 99233 and 99223 are not supported. Our reviewer found 
that the records support that an appropriate history and examination were performed for all codes at issue; 
however, the records do not document high complexity medical decision making for codes 99233 and 99223. 
The records support all criteria for code 99232 but do not support 99233 and 99223. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99233 and 99223 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99233 and 99223. 
 
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.