Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20611. We decided that the Plan does not have to pay for 73562 and 
99213.  
 
You asked the Plan to pay for procedure codes 20611, 73562, and 99214 rendered on March 16, 2023.. 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 20611.  
 
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 20611 is "Arthrocentesis, 
aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound 
guidance, with permanent recording and reporting." 
 
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 20611. Our reviewer says that the enrollee 
complained of right shoulder and right knee pain. CPT 20611 was billed and was appropriate for ultrasound-
guided steroid injection into the right shoulder. 
 
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 
20611.  
 
We also decided that the Plan does not have to pay for 73562 and 99213. 
 
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 the remaining codes is: 
 
CPT 73562: 
 
Radiologic examination, knee; 3 views 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
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 73562 and 99214 Our reviewer says that the physician 
reviewed a 3 view right knee series done on 5/6/22, and billed CPT 73562, which is a 3 view right knee series. 
This was incorrectly coded since the x-rays in question were reviewed only and did not include a technical 
component but only the interpretation of images almost 1 year old. 
 
Additionally, the enrollee was seen for follow-up on right knee and shoulder pain. A right knee examination is 
documented, but not examination of the right shoulder is documented. The enrollee was given an injection of 
Kenalog in the right shoulder joint. Without documentation of the right shoulder, the records do not support a 
medically appropriate examination. Additionally, the provided records in this case do not document 2 out of 3 
of multiple diagnoses or management options, a moderate amount and complexity of data reviewed and 
moderate risk of complication. Therefore, the records do not support medical decision making of moderate 
complexity, and the records do not support CPT 99214. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 73562 and 99213 have not been met. Therefore, we decided that the Plan does 
not have to pay for 73562 and 99213. 
 
 
 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.