Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure codes 99232 and 99233) 
rendered from October 28, 2022, to October 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 the denied codes is: 
 
CPT 99232: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused 
examination; Medical decision making of moderate 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 responding inadequately to 
therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the 
patient's hospital floor or unit. 
 
CPT 99233: 
 
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 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that it is noted that the enrollee may 
have been sedated and unable to fully participate in providing an interval history or review of 
systems. However, the documentation shows limited effort in obtaining an interval history from others, 
examining the enrollee or documenting details of the treatment plan. A lack of punctuation makes sections 
difficult to read/interpret. A non-standard order makes information difficult to find/interpret. The 
documentation is insufficient to support the billing of CPT 99233 on 10/28/2022 and CPT 99232 on 
10/29/2022. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure codes 99232 and 99233) rendered from October 28, 2022, 
to October 29, 2022.