Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from July 7, 2022, through 
July 10, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the services are supported by the records. The 
Plan denied your request. The Plan says the service is not supported by the 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 definition of 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 to pay for the inpatient services. Our reviewer found 
code 99223 is not supported. The provided records in this case do not document a chief complaint, an extended 
history of present illness, a review of all additional body systems and a complete past, family and social 
history. The provided records in this case document a general multisystem examination. The provided records 
in this case do not document 2 out of 3 of an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and high risk of complication. Furthermore, code 99233 is 
not supported. The provided records in this case do not document a chief complaint, an extended history of 
present illness, a problem pertinent review of systems and a pertinent past, family and social history. The 
provided records in this case document an extended examination of the affected body area. The provided 
records in this case do not document 2 out of 3 of an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and high risk of complication. 
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient services provided from July 7, 2022, through July 10, 2022.