This policy describes how UnitedHealthcare reimburses UB claims billed with Evaluation and Management (E/M) codes Level 4 (99284/G0383) and Level 5 (99285/G0384) for services rendered in an emergency department. This policy is based on coding principles established by the Centers for Medicare and Medicaid Services (CMS)1, and the CPT and HCPCS code descriptions.
CMS indicates facilities should bill appropriately and differentially for outpatient visits, including emergency department visits. To that end, CMS coding principles applicable to emergency department services provide that facility coding guidelines should: follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code; be based on hospital facility resources and not based on physician resources; and not facilitate upcoding or gaming.¹
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Q: Can the facility submit a corrected claim if it determines there were additional diagnosis codes not included on the original claim submission, which could have led to the reimbursement at a lower E/M code level other than theE/M code level originally submitted?
A: If the facility did not include all of the relevant and applicable diagnosis codes on its claim, then it could resubmit the claim with appropriate diagnosis code(s) or procedure code(s) which may support the level of E/M code originally submitted. Alternatively, facilities may follow the UnitedHealthcare standard reconsideration and appeals processes for administrative claims determinations as outlined in the administrative guide if they disagree with the reimbursement.
Q: Is the policy applicable to all emergency departments?
A: Yes, this policy is applicable to all emergency departments (whether facility-based, free standing or otherwise). However, a facility may not experience claim adjustments or denials if its billing of level 4 and 5 E/M codes does not disparately deviate from the EDC Analyzer or it submits claims that otherwise meet one of the criteria for exclusion listed in the policy.
Q: Is there additional information available regarding the Emergency Department Claim (EDC) Analyzer?
A: Yes, additional information can be found at the following link: EDCAnalyzer.com