United Healthcare (UHC) will begin evaluating all level 5 professional Emergency Department claims and potentially downcoding them or denying them for “inappropriate” coding. The new policy, which takes effect April 1, 2020, is part of the payer’s “continued efforts to reinforce accurate coding practices.”
Assessing Decision Making
According to UHC, level 5 professional ED claims (CPT code 99285) will be evaluated with the payer’s proprietary Optum Evaluation and Management Professional (E/M Pro) tool. While accurately coding E/M levels relies on three components—History, Exam, and Medical Decision—only medical decision making will be assessed.
“In an effort to reduce the administrative burden of requesting and submitting medical records for review, UnitedHealthcare will … determine appropriate E/M professional coding levels based on data such as patient’s age and conditions for the Medical Decision Making key component,” the payer writes in an announcement about the new policy. “UnitedHealthcare will presume the provider meets the requirements of the E/M code level they have submitted related to the History and Exam key components for the initial adjudication of the claim.”
Later in the statement, UHC says the E/M Pro tool basically calculates the appropriate E/M level based on submitted diagnosis codes, which “will result in fair and appropriate reimbursement for ED services rendered.”
A Limited Story
However, diagnosis codes don’t always tell the whole story.
“The diagnosis codes submitted on the claim in isolation do not give a complete picture of the medical complexity of the patient, or of the medical decision-making undertaken by the physician,” says Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at R1 Physician Advisory Services, in a recent RACMonitor article.
As well, according to Paul Kivela, MD, MBA, FACEP, former president of ACEP, a 2013 study in the Journal of the American Medical Association shows there’s nearly a 90 percent overlap in symptoms between emergencies and non-emergencies. A final diagnosis may not indicate the differential diagnoses a physician is considering when ordering labs and making decisions.
A Familiar Ring
If this new policy has a familiar ring, it’s because this is not UHC’s first attempt to assess and adjust level 5 ED coding. In another policy implemented in 2018, the payer began using their Optum Emergency Department Claim (EDC) Analyzer tool to evaluate level 4 and level 5 facility ED claims for possible denial or reduction of payment for services they deem to be incorrectly coded.
In that case, the EDC uses proprietary algorithms to evaluate the appropriateness of coding levels by looking at data such as the patient’s presenting problem, diagnostic services performed during the visit, and associated patient co-morbidities.
At the time, Hirsch warned that professional claims were likely to come under the same scrutiny at some point in the future and advised physicians to plan ahead with improved documentation.
“One way they can start helping is to ensure that they are including documentation of all comorbid conditions that they considered when evaluating the patient, determining the necessary ED treatment and testing, and deciding on their disposition,” Hirsch wrote.
Prepare for Appeals
When the 2018 facility claims policy was announced, UHC invited facilities to file reconsideration or appeal requests if they received a denial or payment reduction when they believe the originally submitted, higher level code is justified.
While no such invitation was included in this latest policy for professional claims, providers should use their reconsideration and appeal rights as needed. This also makes it even more crucial for providers to compare expected reimbursement with actual payments on EOBs to ensure any denied or reduced claims are quickly identified and appealed.
For more information, review page 38 of the January 2020 UnitedHealthcare Network Bulletin. UHC also suggests contacting your Network Representative or calling Provider Services at 877-842-3210.
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