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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the CPT code
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative
Manual, Chapter I(A).
Medicare guidance says " Physicians must report services correctly. This manual discusses general coding
principles in Chapter I and principles more relevant to other specific groups of HCPCS/CPT codes in the other
chapters. There are certain types of improper coding that physicians must avoid. Procedures should be reported
with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding.
A HCPCS/CPT code may be reported only if all services described by that code have been performed. For
Medicare to consider coverage and payment for any item or service, the information submitted by the supplier
or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met. We have no documentation of critical care time spent to corroborate
the services so we can confirm Medicare coverage has been met. In addition, Critical Care Services and
Physician Time Critical care is a time-based service, and for each date and encounter entry, the physician's
progress note(s) shall document the total time that critical care services were provided. Services provided that
do not meet critical care services or services provided for a patient who is not critically ill or injured in
accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or
other specialized care unit should be reported using another appropriate E/M code (e.g., subsequent hospital
care, CPT codes 99231 - 99233). The CPT critical care codes 99291 and 99292 are used to report the total
duration of time spent by a physician providing critical care services to a critically ill or critically injured
patient, even if the time spent by the physician on that date is not continuous. Physicians of the same specialty
within the same group practice bill and are paid as though they were a single physician (Sec.30.6.5). Critical
Care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical
care codes. This service should be reported using another appropriate E/M code such as subsequent hospital
care. The following illustrates the correct reporting of critical care services: Total Duration of Critical Care
Codes Less than 30 minutes 99232 or 99233 or other appropriate E/M code. An add-on code is eligible for
payment if and only if one of its primary codes is also eligible for payment. An add-on code is a HCPCS/CPT
code that describes a service that is always performed in conjunction with another primary service. An add-on
code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same
practitioner. An add-on code is never eligible for payment if it is the only procedure reported by a practitioner.
You can find this guidance in the: Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician
Practitioners, Section 30 - Correct Coding Policy, Paragraph D. - Coding Services Supplemental to Principal
Procedure (Add-On Codes) Code; Medicare Claims Processing Manual; Chapter 12 - Physician/Non-Physician
Practitioners; Section 30.6.5 - Physicians in Group Practice; Section 30.6.12 - Critical Care Visits and Neonatal
Intensive Care (Codes 99291 - 99292), Paragraph F. - Hours and Days of Critical Care that May Be Billed;
Paragraph G. - Counting of Units of Critical Care Services; NCCI Policy Manual for Medicare Services,
Chapter 1 - General Correct Coding Policies, Section R - Add-on Codes, page I-34;NCCI Policy Manual For
Medicare Services - Chapter 1 - General Correct Coding Policies, Section A. - Introduction, Pages I-7, I-8, I-9
and I-10.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.