Revised and New Emergency Department (ED) Facility Evaluation and Management (E/M) Coding Policies – Effective March 1, 2018
12/14/2017 UnitedHealthcare's December 2017 bulletin provided notice that as part of their continued efforts to reinforce accurate coding practices, UnitedHealthcare will revise the current Emergency Department (ED) Facility Evaluation and Management (E/M) Coding Reimbursement Policy for UnitedHealthcare Commercial Plans and adopt new policies for UnitedHealthcare Medicare Advantage plans, as well as UnitedHealthcare Community Plans in select states.
• The revised policy for UnitedHealthcare Commercial plans will apply to claims with dates of service on or after March 1, 2018.
• The ED Facility E/M Coding Reimbursement Policies for UnitedHealthcare Medicare Advantage plans and select UnitedHealthcare Community Plans will also be effective for dates of service on or after March 1, 2018.
• For information related to reimbursement policies for UnitedHealthcare Community Plans in specific states, please go to UHCCommunityPlan.com > For Health Care Professionals > Select Your State.
These enhancements support UnitedHealthcare’s commitment to the Triple Aim of improving health care services, health outcomes and overall cost of care.
These policies focus on facility ED claims that are submitted with level 4 (99284, G0383) and level 5 (99285, G0384) E/M codes. These policies were developed using UnitedHealthcare's national experience to address inconsistencies in coding accuracy and were based on the E/M coding principles created by the Centers for Medicare & Medicaid Services (CMS) that require hospital ED facility E/M coding guidelines to follow the intent of CPT® code descriptions and reasonably relate to hospitals resource use.
These policies will apply to all facilities, including freestanding facilities, that submit ED claims with level 4 and 5 E/M codes for members of the affected plans, regardless of whether they’re under contract to participate in the UnitedHealthcare network.
As part of the implementation of these policies, UnitedHealthcare will begin using the Optum Emergency Department Claim (EDC) Analyzer tool, which determines appropriate E/M coding levels based on data such as the patient’s presenting problem, diagnostic services performed during the visit and associated patient co-morbidities. To learn more about the EDC Analyzer tool, please visit EDCAnalyzer.com.
Facilities submitting claims for ED E/M codes may experience adjustments to level 4 or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial, based on the reimbursement structure within their agreements with UnitedHealthcare.
Facilities will have the opportunity to submit reconsideration or appeal requests if they believe a higher level E/M code is justified, in accordance with the terms of their contract and/or Administrative Guide.
Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:
• Admissions from the emergency department
• Critical care patients
• The patient is 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 abnormally deviate from the EDC Analyzer tool determination
If you need further information, please contact your Network Representative or call Provider Services at 877-842-3210.