May 07, 2018
Area(s) of Interest: Commercial Payors Emergency Services Hospitals and Health Facilities Payor Issues and Reimbursement
Citing the need to address inconsistencies in coding, UnitedHealthcare (UHC) recently altered its Emergency Department (ED) Facility Evaluation and Management (E/M) Coding Policy to include an analysis of the appropriateness of submitted high level facility E/M codes. Utilizing the Optum Emergency Department Claim (EDC) Analyzer tool, UHC will apply an algorithm to determine the UHC calculated visit level for the emergency department E/M services rendered. Facilities whose level 4 (99284, G0383) or level 5 (99285, G0384) codes (for dates of service on or after March 1) are submitted at a higher level than the UHC calculated visit level may experience downcoding of their submitted codes or denials of their claims as submitted. The EDC Analyzer will take into consideration the following factors:
- Presenting problems – as defined by the ICD-10 reason for visit diagnosis
- Diagnostic services performed – based on intensity of the diagnostic workup as measured by the diagnostic CPT codes submitted on the claim (i.e. lab, x-ray, EKG/RT/other diagnostic, CT/MRI/ultrasound)
- Patient complexity and co-morbidity – based on complicating conditions as defined by the ICD-10 principal and secondary diagnosis code
Criteria that may exclude facility claims from being subject to an adjustment or denial include:
- Patients who are admitted to inpatient, observation or have an outpatient surgery during the course of the same ED visit
- Critical care patients (99291, 99292
- Patients less than 2 years old
- Claims with certain diagnosis that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time
- Patients who have expired in the emergency department
- Claims from facilities whose billing of level 4 and 5 E/M codes does not disparately deviate from the EDC Analyzer.
The California Medical Association (CMA) has raised concerns with UHC regarding the altered facility E/M coding policy, citing the potential to alter and reduce compensation of associated emergency room physician services. While UHC has advised that the facility E/M coding policy will only apply to facility services and will have no impact upon physicians, CMA will continue to monitor the situation in the wake of the recently announced Health Net Non-emergent Emergency Room Services policy, which aims to reduce reimbursement for level 4 (CPT 99284) and level 5 (CPT 99285) emergency room services to a level 3 (CPT 99283) contracted rate for services provided to patients who Health Net deems to have a non-emergent diagnosis.
More information regarding this change can be found on the UHCProvider.com website, or providers can contact UHC at (877) 842-3210 for additional information.