ED Coding and Reimbursement Alert

Getting to know UHC’s definition can help you calculate MDM.

According to CMS data, about half of ED claims are reported with code 99285 (Emergency department visit for the evaluation and management of a patient...), but that number could be dramatically different for one payer, due to a unilateral interpretation of a medical decision making (MDM) rule that has been causing confusion for quite a while now.

Background: UnitedHealthcare (UHC) has decided to try and make it more challenging to report ED code 99285. For the past two years, UHC’s coding policy has attempted to advance an interpretation related to how many points can be counted toward diagnoses and management options when calculating the MDM portion of an E/M service in the emergency department. That policy has caused a high level of confusion among EDs, since it is fairly unique to UHC, and on September 1, 2020, UHC issued an E/M policy aimed at EDs that clarifies how the guidelines work.

To break down exactly what UHC is attempting to unilaterally impose for 99285, check out the scoop straight from UHC’s policy.

Discover How to Qualify for 4 Points

The UHC policy states, “A provider receives three points for ‘New Problem, No Additional Work-Up Planned,’ and four points for ‘New Problem, Additional Work-Up Planned.’ This one-point difference can affect whether a level four or level five code is appropriate. Note that all encounters with ED patients are considered ‘New Problem’ encounters for purposes of scoring.”

In addition, UHC defines “additional workup planned” using the following terminology: “Any testing/consultation/ referral that is being done beyond that encounter to assist the provider in medical decision making.” This is a rather vague description, and could leave EDs with more questions than answers. Additionally, the policy is unique to UHC, making it challenging to address.

To quell confusion, UHC offers this example of additional workup planned: “If the physician schedules testing him/herself or communicates directly with the patient’s primary physician or representative the need for testing which is to be done after discharge from the ED, and the appropriate documentation has been recorded. Credit for ‘additional workup’ planned is granted (4 points assigned). Credit is not given for the work up if it occurs during the ER encounter.”

David McKenzie, reimbursement director for the American College of Emergency Physicians (ACEP) says, “ACEP’s position is that if the goal is to measure medical decision making and additional testing is required to determine the diagnosis and treatment plan, how is that cognitive process different if it occurs after the encounter when test results are obtained in an office setting, as opposed to some hours later while the patient is still in the ED? The cognitive work is the same, or even more difficult because of the relative greater intensity of the typical level five ED visit. ED visits should not be arbitrarily penalized because the ED has greater access to testing 24/7/ 365. In fact, incorporation of additional complex testing and advanced labs into the ED medical decision making process only serves to heighten the cognitive intensity of the service. In both cases, the physician would have a second medical decision-making interaction with the patient based on the new data to be reviewed and analyzed. In the ED setting it occurs more quickly since these are often high acuity time sensitive conditions.”

UHC also notes, “Patients admitted to the hospital under the care of a physician other than the ER physician may have testing done as part of the admitting physician’s care for that patient. The ER physician will not receive credit for the Additional Work-Up Planned done under the care of the admitting physician.”

Medicare, CPT^® Guidelines Don’t Use These Terms

Ever since UHC first rolled out this change, coders have written to ED Coding Alert asking about how it meets Medicare guidelines. For instance, Tammy James, an ED coder in Atlanta, Georgia, wrote, “I am not seeing any mention of ‘additional workup planned’ in either CPT^® or the Medicare rules, which makes this very confusing.”

UHC addressed that as well, noting that “This interpretation is consistent with the level 5 code description that ‘…Usually, the presenting problem(s) are ofhigh severity and pose an immediate significant threat to life or physiologic function….’” However, this statement acknowledges that UHC has adopted its own interpretation of the guidelines, and it’s clearly specific to just that one payer.

Appeal When Necessary

Although UHC’s policy may be frustrating for some EDs who are unfamiliar with the “additional workup planned” verbiage, you still have the option of appealing claim denials when you feel a 99285 is justified.

If UHC reviews your chart documentation and denies a claim with 99285, you can write an appeal letter explaining why you believe your documentation demonstrates additional workup planned. And if you do not think additional workup planned should even be used as a term to determine your E/M levels, then you can use that argument in your letter. You can say you treated extensive diagnoses and management options for the patient, and that this justifies the code.

Resource: To read UHC’s September 2020 policy in its entirety, visit www.uhcprovider.com/content/dam/provider/docs/public/policies/oxford/em-ohp.pdf.