Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93320, 93225, and 99220 rendered on 
December 27, 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 documents do not support this level of care. 
 
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 93225: 
 
External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording 
(includes connection, recording, and disconnection) 
 
CPT 93320: 
 
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 
addition to codes for echocardiographic imaging); complete 
 
CPT 99220: 
 
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 
 
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 the documentation from this date 
describes the patient with persistent symptomatic atrial flutter being treated with amiodarone and 
anticoagulation for a cardiology consultation. However, the documentation does not support a comprehensive 
history or examination. The vitals were normal and stable. The plan included cardioversion which was 
performed in addition to echocardiogram. The documentation does not support medical decision-making of 
high complexity for this encounter or that 70+ minutes were spent on this encounter. Although the enrollee did 
undergo electrocardiogram and echocardiogram, they were performed as part of the cardioversion procedure. 
They would only be included in the coding for the cardioversion procedure. There was insufficient support 
made in the documentation for these to be coded separately as they were not independent of this procedure. 
Therefore, the codes 93225, 93320, and 99220 are each not supported in the documentation for this date. 
 
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 93320, 93225, and 99220 rendered on December 27, 2022.