In their January 2020 network bulletin , UnitedHealthcare (UHC) announced a new Emergency Department professional evaluation and management policy . The new policy becomes effective on April 1, 2020. UHC stated in their bulletin that they “will begin using the Optum® Evaluation and Management Professional (E/M Pro) tool which determines appropriate E/M professional coding levels based on data such as patient’s age and conditions for the Medical Decision Making key component.” UHC warned providers that they might begin to see adjustments or denials to level 5 E/M code 99285, depending on reimbursement structures outlined in their contracts. Presumably, the adjustments or denials will occur automatically as UHC stated that the change in policy is an effort to “reduce the administrative burden of requesting and submitting medical records for review.”
UHCs policy allows the following exceptions to adjustments or denials:
• The patient is admitted to inpatient, observation, or has an outpatient surgery during the course of the same ED visit;
• Critical care patients (99291, 99292);
• 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; or
• Claims from facilities who’s billing of level 4 and 5 E/M codes does not disparately deviate from the EDC Analyzer.
The policy applies to all emergency departments, whether facility-based or freestanding. Providers receiving adjustments or denials can appeal through the usual channels.
There are no national guidelines established for emergency department E/M billing. In 2007, CMS addressed the use of Emergency Department visit HCPCS codes 99281 – 99285 in the Federal Register, 72 FR 66789 , reiterating numerous times the lack of national guidelines for reporting E/M services. CMS stated that they instructed hospitals in 2000 to report facility services for Emergency Department visits using CPT E/M codes (65 FR 18434). CMS also stated at the time that “hospitals should continue using their own internal guidelines to determine the appropriate reporting of different levels of clinic and emergency department visits.”
1 – https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2020/network-bulletin/january-2020-network-bulletin.pdf.
2 – Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy, Policy Number 2018R6007A, https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-reimbursement-policies.html
3 – https://www.govinfo.gov/content/pkg/FR-2007-11-27/pdf/07-5507.pdf
Spring 2020 will tell us how successful UHC might be in enforcing its policy to police emergency department E/M billing with a proprietary tool that does not appear to support CMS instruction. The Optum® Evaluation and Management Professional (E/M Pro) tool can be found here: https://edcanalyzer.com/
Denise serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a Master’s degree in Management Information Systems from the University of Illinois, Springfield.
Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.
Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.