Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital evaluation and management (EM) services 
provided on September 4, 2022, and September 5, 2022, billed with codes 99220 and 99225, respectively. 
 
You asked the Plan to pay for the EM services as billed. You say that the services were billed correctly. The 
Plan denied your request. The Plan says the codes billed are 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 code 99220 is initial observation 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 to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. The CPT definition of 99225 is subsequent observation 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 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 EM services as billed. Our reviewer says 
that the billed EM services are not supported.  Our reviewer found for code 99220, the history of the progress 
note had detail, and the physical exam included appropriate systems. There was no complex decision making. 
The enrollee had a painful weak knee chronically with no acute injury. There was no indication for extensive 
data review or care coordination. There were limited therapeutic options, and the options did not carry 
significant risks. For 99225, no progress note for this date was submitted for review. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital evaluation and management (EM) services provided on September 4, 
2022, and September 5, 2022, billed with codes 99220 and 99225, respectively.