Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial and subsequent hospital care (procedure codes 99223 
and 99233) provided from September 2, 2022, to September 3, 2022. 
 
You asked the Plan to pay for initial and subsequent hospital care (procedure codes 99223 and 99233). You say 
that procedure codes 99223 and 99233 are appropriate based on the level of services required. The Plan denied 
your request. The Plan says the services at issue in this case are not supported by the medical records. 
 
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 CPT Code Manual definition of code 99233 is subsequent hospital 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 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 complication or a significant new problem. Typically, 35 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 initial and subsequent hospital care (procedure codes 99223 
and 99233). Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our reviewer found the documentation supports an appropriate exam, but not an appropriate history or medical 
decision making of high level, or that 70 minutes were spent, so code 99223 is not supported. The 
documentation supports an appropriate exam, but not an appropriate history or medical decision making of 
high level, or that 35 minutes were spent, so code 99233 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 initial and subsequent hospital care (procedure codes 99223 and 99233) have 
not been met. Therefore, we decided that the Plan does not have to pay for initial and subsequent hospital care 
(procedure codes 99223 and 99233) provided from September 2, 2022, to September 3, 2022.