Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99306, 99309, and 99310 rendered from 
October 10, 2022, to December 15, 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 denied codes remain 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 the denied codes is: 
 
CPT 99306: 
 
Initial nursing facility care, per day, for the evaluation and management of a 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 problem(s) requiring admission are of high severity. Typically, 45 minutes are 
spent at the bedside and on the patient's facility floor or unit 
 
CPT 99309: 
 
Subsequent nursing facility 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 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 has developed a significant complication or a significant new 
problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
CPT 99310: 
 
Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at 
least 2 of these 3 key components: A comprehensive interval history; A comprehensive 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. The patient may be unstable or may have developed a significant new 
problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the 
patient's facility 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 there were no records provided 
for the dates of service at issue in this case. As such, the billing of these codes is not supported. 
 
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 procedure codes 99306, 99309, and 99310 rendered from October 10, 2022, to December 15, 
2022.