Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99345, 99348 and 99349 billed for dates of 
service March 29, 2022, to April 30, 2022. 
 
You asked the Plan to pay for procedure codes 99345, 99348 and 99349. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
services billed. 
 
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 99345, 99348 and 99349 is: Home visit for the evaluation 
and management of a new patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 new problem requiring immediate physician attention. Typically, 75 minutes are spent 
face-to-face with the patient and/or family. 
 
The definition of code 99348 is: Home visit for the evaluation and management of an established 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 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 presenting 
problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or 
family. 
 
The definition of code 99349 is: Home visit for the evaluation and management of an established patient, 
which requires at least 2 of these 3 key components: A detailed interval history; A detailed 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 presenting problem(s) are moderate to high 
severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. 
 
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 procedure codes 99345, 99348 and 99349. Our reviewer says 
that procedure codes 99345, 99348 and 99349 do not meet criteria for payment. Our reviewer found that code 
99345 is not supported because the medical records submitted do not support a comprehensive history, a 
comprehensive examination and medical decision making of high complexity. Code 99348 is not supported 
because the medical records submitted do not include home or residence visit evaluation and management note 
for the billed dates of service. Code 99349 is not supported because the medical records submitted do not 
support a detailed interval history, a detailed examination and medical decision making of moderate 
complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99345, 99348 and 99349 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99345, 99348 and 99349 billed for dates of 
service March 29, 2022, to April 30, 2022.