This reimbursement policy applies to services reported using the UB04 claim form or its electronic equivalent or its successor form. This policy applies to claims submitted on such forms by network and non-network facility emergency departments (including hospital emergency departments) and free-standing emergency departments (UB Claims).
Codes: 99284 99285 99291 99292 G0383 G0384
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies may use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement.
This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy.
This information is intended to serve only as a general reference resource regarding UnitedHealthcare’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy.
These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, the enrollee’s benefit coverage documents and/or other reimbursement, medical or drug policies.
Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations. UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication.
*CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
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), and the CPT and HCPCS code descriptions.
Codes: 99284 99285 99291 99292 G0383 G0384
CMS Coding Principles
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.
UB04 Claims for services rendered in an emergency department should be complete and include all diagnostic services and diagnosis codes relevant to the emergency department visit and be billed at the appropriate E/M level.
UnitedHealthcare will utilize the Optum Emergency Department Claim (EDC) Analyzer to determine the emergency department E/M level to be reimbursed for certain facility claims. The EDC Analyzer applies an algorithm that takes three factors into account in order to determine a Calculated Visit Level for the emergency department E/M services rendered. The three factors used in the calculation are as follows:
• Presenting problems – as defined by the ICD-10 reason for visit (RFV) diagnosis;
• Diagnostic services performed – based on intensity of the diagnostic workup as measured by the diagnostic CPT codes submitted on the claim (i.e., Lab, X-ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound); and
• Patient complexity and co-morbidity – based on complicating conditions or circumstances as defined by the ICD-10 principal, secondary, and external cause of injury diagnosis codes.
Facilities may experience adjustments to the level 4 or 5 E/M codes submitted to reflect a lower E/M code calculated by the EDC Analyzer or may receive a denial for the code level submitted. For certain facilities who experience adjustments to a level 4 or 5 E/M code, we may estimate reimbursement for the adjusted code based on historical claims experience, and in such event the facility may resubmit an adjusted claim which we will adjudicate based on the new charges submitted in accordance with this policy.
Criteria that may exclude Facility claims from being subject to an adjustment or denial include:
• The patient is admitted to inpatient, has an outpatient surgery during the course of the same ED visit, or is discharged/transferred to other types of health care institutions;
• Critical care patients (99291, 99292);
• The patient is less than 2 years old;
• Claims with certain diagnosis that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time;
• Patients who have expired in the emergency department; or
• Claims from facilities billing level 4 and 5 E/M codes that do not deviate from the EDC Analyzer.
UnitedHealthcare and Optum are related companies through common ownership by UnitedHealth Group. For additional information on the EDC Analyzer, visit EDCAnalyzer.com.
Questions and Answers:
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 the E/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 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
UnitedHealthcare Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy, Facility, 2023
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services.
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services
Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets
Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI) Policy Publications
Commercial Reimbursement Policy UB04
Policy Number 2023R6003A
Billing Executive – a Medical Billing and Coding Knowledge Base for Physicians, Office staff, Medical Billers and Coders, including resources pertaining to HCPCS Codes, CPT Codes, ICD-10 billing codes, Modifiers, POS Codes, Revenue Codes, Billing Errors, Denials and Rejections.