January 2020 ~

UnitedHealthcare (UHC) has announced that starting April 1, 2020, they will use a proprietary software program to evaluate all professional claims submitted for emergency department visits with the Level 5 evaluation and management (E/M) code 99285.

According to guidelines from the American Medical Association (AMA), Emergency Department (ED) E/M codes must meet or exceed all 3 key components. A Level 5 emergency department visit requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Therefore, when only 2 of the 3 key components meet or exceed the requirement to qualify for a particular level of E/M service the third key component is utilized to select the appropriate level of E/M service. In order to determine the complexity of medical decision-making, the AMA guide requires a review of the number and complexity of problems considered, the amount and/or complexity of data reviewed, and an assessment of risk.

In an effort to reduce the administrative burden of requesting and submitting medical records for review, UnitedHealthcare 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. 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.

The E/M Pro tool accounts for diagnosis codes submitted on the claim and determines the appropriate level of complexity that correlates with the E/M professional service reimbursement. Since medical decision making and problem complexity is the primary driver, the E/M Pro tool calculates the appropriate E/M level based on submitted diagnosis codes. This will result in fair and appropriate reimbursement for ED services rendered. Providers submitting professional claims for ED level 5 E/M code 99285 may experience adjustments to reflect an appropriate level E/M code or may receive a denial, based on the reimbursement structure within their agreements with UnitedHealthcare.

Source(s): January 2020 Network Bulletin – UnitedHealthcare; RAC Monitor;