UnitedHealthcare cracks down on level 4, 5 ED codes UnitedHealthcare cracks down on level 4, 5 ED codes

UnitedHealthcare cracks down on level 4, 5 ED codes

Providers who submit claims to UnitedHealthcare (UHC) have begun seeing a dramatic change in coding policy, with all facility emergency department (ED) visits coded at level 4 or level 5 undergoing review for adjustment or outright denial.

The new policy took effect March 1 and affects both UHC’s commercial plans and its Medicare Advantage plans, as well as claims submitted to UHC from non-participating facilities.

Simply selecting ED codes 99284 and 99285, which represent moderate complexity and high complexity cases, will result in the claim being reviewed by UHC using the Optum Emergency Department Claim (EDC) Analyzer tool, which is a software module that supposedly “systematically evaluates each ED visit level code in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender) to ensure that it reasonably relates to the intensity of hospital resource utilization as required per CMS Guidelines.”

The other ED codes (99281-99283) in the same CPT family will not be subject to this automatic review using the EDC tool, UHC said in its bulletin, which was released in December. Those facilities submitting claims with 99284 or 99285 will have those claims “adjusted” in level, which is to say downcoded, or completely denied, based on “the reimbursement structure within their agreements with UnitedHealthcare,” UHC states.

There are some exceptions to the automatic EDC review, which are:

  • Admissions from the ED;
  • Critical care patients;
  • Patients younger than 2 years of age;
  • Certain diagnoses requiring greater than average resource use when performed in the ED;
  • Patients who die in the ED; and,
  • Facilities whose billing of level 4 and 5 E/M codes does not abnormally deviate from Optum’s EDC Analyzer tool determination.

Facilities that see either a reduction in their ED code levels or denials will be able to submit reconsideration or appeal requests if they disagree with the EDC analyzer’s findings and the subsequent “adjustments,” according to the UHC bulletin. The massive increase in scrutiny created by this new policy is needed, UHC states, to “support UnitedHealthcare’s commitment to the triple aim of improving health care services, health outcomes and overall cost of care.”

What to do next…

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  2. Read more: What can you expect from a coding and compliance review?

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