Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99232 provided on August 22, 
23, 24, 2022. 
 
You asked the Plan to pay for procedure codes 99223 and 99232. You say that the medical records support the 
billing of procedure codes 99223, 99232, and 99232 provided on August 22, 23, and 24, 2022.  The Plan 
denied your request. The Plan says the medical records do not support the billing of procedure codes 99223, 
99232, and 99232 provided on August 22, 23, and 24, 2022.  
 
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 99223 is Initial hospital 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, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. The definition of code 99232 is 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. 
 
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 99223 and 99232. Our reviewer says that 
the medical records do not support the billing of procedure codes 99223, 99232, and 99232 provided on August 
22, 23, and 24, 2022.  Our reviewer found for the date of service August 22,2022 Current Procedural 
Terminology (CPT) code 99223 (1 Unit) was not supported. This initial hospital care evaluation and 
management code requires a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. In this case, the medical records submitted did not support a comprehensive 
history, a comprehensive examination and medical decision making of high complexity. 
 
For the dates of services August 23 and 24, 2022, Current Procedural Terminology (CPT) code 99232 (1 Unit) 
was not supported. This subsequent hospital care evaluation and management code requires two out of these 
three key components: an expanded problem focused interval history, an expanded problem focused 
examination and medical decision making of moderate complexity. In this case, the medical records submitted 
did not support an expanded problem focused interval history 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 99223 and 99232 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99232 provided on August 22, 23, 24, 2022.