Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to pay for hospitalist services (99223 and 99232) provided on January 31, 2023 and 
February 2, 2023. You say that you are appealing with supporting records. The Plan says that the records do 
not support the level of decision-making or time component for these codes. 
 
We decided that the Plan has to pay for 99223.  
 
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 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 99223. Our reviewer says that the records support payment 
of 99223. Our reviewer found the procedure report supports a high level of medical decision-making. Medical 
record includes documentation of intravenous heparin, which is a drug therapy requiring intensive monitoring 
toxicity which can have a high risk of morbidity due to treatment. Therefore, this level should be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 have been met. Therefore, we decided that the Plan has to pay for 99223.  
 
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. In this case, the CPT Code Manual definition of 
code 99232 is subsequent 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 moderate level of medical 
decision making. When using total time on the date of the encounter for code selection, 35 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 99232. Our reviewer says that the records do not support 
payment of 99232. Our reviewer found the procedure report does not support criteria to support a moderate 
level of decision-making to include responding inadequately/minor complication. In this case, there is a more 
appropriate code to report for the services documented. 
 
We looked at this coder'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.