Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient evaluation and management (EM) services provided from 
October 3, 2022, to October 6, 2022, billed with 99233, and the discharge management services provided on 
October 7, 2022, billed with code 99239. 
 
You asked the Plan to pay for the EM services at issue. You say that these services should be paid as billed.  
The Plan denied your request. The Plan says that the requested medical records were not submitted, and as 
such, it cannot be determined that the codes are supported.  
 
Please note: We found that the records noted as not submitted were, in fact, present in the case file sent by the 
Plan. As such, these records were reviewed.  
 
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 care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high 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 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. The definition of code 99239 is hospital 
discharge day management; more than 30 minutes. 
 
We asked our physician reviewer 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 EM services at issue. Our reviewer says 
that the records submitted support the EM services as billed. Our reviewer found for the October 3 date of 
service (DOS), records document a detailed interval history with a chief complaint, an extended history of 
present illness and a problem pertinent review of systems; records include an extended examination of the 
affected body area, and other symptomatic or related organ systems and records include 2 out of 3 of an 
extensive number of diagnoses or management options, an extensive amount and complexity of data reviewed 
and high risk of complication.  
 
For the October 4 DOS, records do not document a detailed interval history with an extended history of present 
illness. Provided records do include an extended examination of the affected body area and other symptomatic 
or related organ systems. Records include 2 out of 3 of an extensive number of diagnoses or management 
options, an extensive amount and complexity of data reviewed and high risk of complication. 
 
For the October 5 and October 6 DOS, provided records do include an extended examination of the affected 
body area and other symptomatic or related organ systems. Provided records include 2 out of 3 of an extensive 
number of diagnoses or management options, an extensive amount and complexity of data reviewed and high risk of complication.  
 
In addition, we find that code 99239 is supported as the progress note does document that more than 30 
minutes were spent. 
 
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 EM services at issue have not been met. Therefore, we decided that the Plan 
has to pay for the inpatient evaluation and management (EM) services provided from October 3, 2022, to 
October 6, 2022, billed with 99233, and the discharge management services provided on October 7, 2022, 
billed with code 99239.  
 
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.