Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 73525. We decided that the Plan does not have to pay 
for procedure codes 99232 and 99223.  
 
You asked the Plan to pay for procedure codes 99232, 99223, and 73525 provided from May 7, 2023, to May 
11, 2023. You say that you are requesting the claim be reviewed and reprocessed for payment. The Plan says 
that the records do not support the services at issue in this case. 
 
We decided that the Plan has to pay for procedure code 73525.  
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. 
 
In this case, the CPT Code Manual definition of code 73525 is radiologic examination, hip, arthrography, 
radiological supervision and interpretation. 
 
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 item/service at issue. Our reviewer says 
that the services at issue in this case are partially supported by the medical records. Our physician reviewer 
found that the documentation does support that a radiologic examination, represented by CPT 73525, was 
performed.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for procedure code 73525.  
 
We also decided that the Plan does not have to pay for procedure codes 99232 and 99223. 
 
The Plan follows Medicare rules. Medicare rules say that practitioners will select visit level based on the level 
of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner.   
 
In this case, the CPT Code Manual definition of the denied codes are: 
 
1. CPT 99232: 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. 
 
2. CPT 99223: 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 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 item/service at issue. Our reviewer says 
that the services at issue in this case are partially supported by the medical records. Our physician reviewer 
found that there was a medically appropriate examination, but not an appropriate history or moderate level of 
decision making, or that 35 minutes were spent to support the billing of CPT 99232. The documentation does 
not support an appropriate history, high level of decision making, or that 75 minutes was spent to support the 
billing of CPT 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 the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99232 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.