News: Automated downgrade of emergency physician visit codes coming April 1

UnitedHealthcare (UHC) announced that starting April 1, 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), a Level 5 emergency department visit requires a comprehensive history, examination, and high complexity medical decision-making. To determine the complexity of said decision-making, the AMA guide requires a review of the number and intricacy of problems that were considered, the data reviews, and an assessment of risk.

However, the UHC announcement notes that the Optum Evaluation and Management Professional tool will determine the “correct” code. The proper code will be based solely on the patient’s age and diagnoses submitted on the claim. If the tool determines the submitted diagnoses should have a lower level code, the claim will either be automatically adjusted for such or will be denied. Denials for this reason are “based on the reimbursement structure” in their contract.

UHC notes that the policy of automated downgrading is “part of our continued efforts to reinforce accurate coding practices,” and uses such as justification for the changes. It also mentions that medical records will not be requested “in an effort to reduce the administrative burden of requesting and submitting medical records for review.”

Editor’s note: The UHC announcement can be found here.