Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99224, 99217, and 95720 for date of service 
September 21, 2022, to September 23, 2022. 
 
You asked the Plan to pay for procedure codes 99224, 99217, and 95720. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 99224 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused 
interval history; Problem focused examination; Medical decision making that is straightforward or 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 stable, recovering, or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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.]) 
 
The CPT Code Manual definition of code 95720 is electroencephalogram (EEG), continuous recording, 
physician or other qualified health care professional review of recorded events, analysis of spike and seizure 
detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report 
after each 24-hour period; with video (VEEG). 
 
We find that CPT codes 99224, 99217, and 95720 are not supported in the medical record. Specifically, codes 
99224 and 99217 require a designation of observation status. The medical records submitted did not indicate 
that the enrollee's status is designated for observation. The submitted medical records do not include the 
duration for which electroencephalogram (EEG), continuous recording, physician or other qualified health care 
professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 
12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; with video 
(VEEG) performed; therefore, code 95720 is not supported. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99224, 99217, and 
95720 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99224, 
99217, and 95720 for date of service September 21, 2022, to September 23, 2022.