Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99239. We decided that the Plan does not have to pay for 99233.  
 
You asked the Plan to pay for hospital care (procedure code 99233 and 99239) rendered from October 12, 
2022, to October 13, 2022.. You say that this should be paid for. The Plan says that the denied codes remain 
not supported. 
 We decided that the Plan has to pay for 99239.  
 
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 CPT 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
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 for CPT 99239. Our reviewer says that the 
documentation does support the use of this code, with documentation of more than 30 minutes rendered of 
hospital discharge day management. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
99239.  
 
We also decided that the Plan does not have to pay for 99233. 
 
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 CPT 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 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 for CPT 99233. Our reviewer says that the 
documentation does not provide evidence of a detailed history, examination, or medical decision-making of 
high complexity. The records do not support CPT 99233. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99233 have not been met. Therefore, we decided that the Plan does not have to 
pay for 99233. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.