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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The Medicare guidelines say, "CPT code 99153 have Professional Component (PC)/Technical Component 
(TC) Indicator 3." You can find this guidance in the 2022 National Physician Fee Schedule Relative Value File 
April Release. 
 
The Medicare guidelines say "Professional Component (PC)/Technical Component (TC) Indicator 3 Technical 
component only codes: 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-only tests. It also identifies codes that are covered only as diagnostic 
tests and therefore, do not have a related professional code. The total RVUs for technical component only 
codes include values for practice expense and malpractice expense only." You can find this guidance in the 
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements, 
Section 50.6  Physician Fee Schedule Payment Policy Indicator File Record Layout. 
 
The Medicare guidelines say, "21 Inpatient Hospital-A facility, other than psychiatric, which primarily 
provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the 
supervision of physicians to patients admitted for a variety of medical conditions." You can find this 
guidance in the Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form CMS- 
1500 Data Set, 10.5 - Place of Service Codes (POS) and Definitions. 
 
The Medicare guidelines say "The work (or professional) component of physicians services refers to the 
resources used in furnishing the service that reflect physician time and intensity. The technical component (or 
practice expense [PE]) refers to the portion of resources involved in furnishing services (such as equipment 
costs, office rent, and wages of personnel) As part of the CY 2020 Final Rule, CPT code 99153 was established 
as a PE-only code meaning there is no work component RVU associated with that service. The CY 2020 Final 
Rule established CPT codes 99151, 99152 and 99155- 99157 as representative of the work component for 
moderate sedation services." You can find this guidance in the CY 2020 Final Rule. 
 The Medicare guidelines say "As specified in section 1848(c)(1)(A) of the Act, the work component of 
physicians services means the portion of the resources used in furnishing the service that reflects physician 
time and intensity. We were required to consider general categories of expenses (such as office rent and wages 
of personnel, but excluding MP expenses) comprising PEs. The PE RVUs continue to represent the portion of 
these resources involved in furnishing PFS services. Following the publication of the CY 2021 PFS final rule, a 
stakeholder contacted us regarding what they believed to be an error in the intraservice work time for HCPCS 
code G0500 (Moderate sedation services provided by the same physician or other qualified health care 
professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of 
an independent trained observer to assist in the monitoring of the patients level of consciousness and 
physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may 
be reported with 99153, as appropriate)). For a full discussion of this topic, we refer readers to the CY 2017 
PFS final rule (81 FR 80339 through 80349)." You can find this guidance in the CY 2022 Final Rule.  
 
The Medicare guidelines say "The A/B MACs (A) must provide a listing of the required data elements, 
including a brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the 
distinction between submissions which are not considered claims, but which are returned to provider (RTP) and 
submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted 
as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected 
on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected 
and resubmitted." You can find this guidance in the Medicare Claims Processing Manual Chapter 1 - General 
Billing Requirements Section 70.2.3.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.