Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home evaluation and management (EM) services 
provided on August 23, 2022, billed with codes 99345, 99354, 99355, and 99497. 
 
You asked the Plan to pay for the EM services as billed. You say that this claim was billed correctly.  The Plan 
denied your request. The Plan says the codes used to bill this visit are not supported. 
 
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 99345 is home visit for the evaluation and management 
of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face 
with the patient and/or family. The definition of 99354 is home visit for the evaluation and management of a 
new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; 
and Medical decision making of high 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 unstable or has developed a 
significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face 
with the patient and/or family. The definition of 99355 is prolonged service(s) in the outpatient setting 
requiring direct patient contact beyond the time of the usual service; each additional 30 minutes (List separately 
in addition to code for prolonged service). The definition of code 99497 is advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. 
 
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 to pay for the EM services as billed. Our reviewer says 
that the billed codes are not supported by the records provided.  Our reviewer found the progress note 
documents no physical exam, no coordination of services, and no evidence of a prolonged visit as the visit was 
limited to history and lab review. The history was somewhat detailed, but the history of present illness was 
brief, and there was no review of systems. There was also no review of advanced directives or complex 
decision making. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the home evaluation and management (EM) services provided on August 23, 
2022, billed with codes 99345, 99354, 99355, and 99497.