Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152, 99223, and 99153 for dates of service 
December 17, 2022. 
 
You asked the Plan to pay for procedure code 99152, 99223, and 99153. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
The CPT Code Manual definition of code 99223 is Initial hospital inpatient or observation care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 75 minutes must be met or exceeded. 
 
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 procedure code 99152, 99223, and 99153. Our reviewer says 
that the documentation does not support the services billed. Our reviewer found a comprehensive examination 
requires a general multisystem examination or a complete examination of a single organ system. Provided 
records in this case do not document a general multisystem examination or a complete examination of a single 
organ system. Therefore, code 99223 is not supported. The provided records in this case do not document the 
presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness 
and physiological status. Therefore, code 99152 is not supported. 
 
Code 99152 has a Professional Component (PC)/Technical Component (TC) Indicator of 3. This means this is 
a technical component only code. This indicator identifies stand-alone codes that describe the technical 
component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code 
that describes the professional component of the diagnostic tests only. It also identifies codes that are covered 
only as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be 
used with these codes. The total relative value units for technical component only codes include values for 
practice expense and malpractice expense only. This code was billed with a place of service of 21 (inpatient). 
This code is not payable as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99152, 99223, and 99153 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99152, 99223, and 99153 for dates of service 
December 17, 2022.