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 99232.  
 
You asked the Plan to pay for procedure codes 99232 and 99239 rendered from October 20, 2022, to October 
27, 2022.. You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
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. The 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 medical 
records include a discharge note with the time documented as greater than 30 minutes. 
 
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 99232. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 99232 is "Subsequent 
hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key 
components: An expanded problem focused interval history; An expanded problem focused examination; 
Medical decision making of moderate 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 responding inadequately to therapy or 
has developed a minor complication. Typically, 25 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 99232 from October 20, 2022, to October 22, 
2022. Our reviewer says that the records do not include evaluation and management notes for these dates of 
service. Therefore, CPT 99232 cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99232 have not been met. Therefore, we decided that the Plan does not have to 
pay for 99232. 
 
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.