United Healthcare ED Changes Impact Level 4 and Level 5 Services

Expect denials as the healthcare giant is cracking down on Levels 4 and Level 5

UnitedHealthcare (UHC) will reportedly review and possibly adjust or deny facility emergency department (ED) claims submitted with Level 4 and Level 5 evaluation and management (E&M) codes, with facilities able to submit reconsideration or appeal requests. These codes include the following:

99284: Usually, the presenting problem(s) are of high severity and require urgent evaluation by the physician, but do not pose an immediate significant threat to life or physiologic function.

For physician E&M length of stay (LOS) billing, 99284 requires these three key components:

  •  A detailed history;
  • A detailed examination; and
  • Medical decision-making of moderate complexity.

There is no national standard for hospital ER coding. As part of the Outpatient Prospective Payment System (OPPS), Medicare requires hospitals to create their own facility billing guidelines. Coding guidelines should be:

  • Based on facility resources
  • Clear and easy to understand
  • Requiring compiling documentation that is clinically necessary for patient care

99285: Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Professional billing of a 99285 E&M LOS requires these three key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status:

  •  A comprehensive history; 
  •  A comprehensive examination; and
  • Medical decision-making of high complexity.

Again, for hospitals there are no such clear-cut guidelines.

Institutions with employed physician groups that can access the pro-fee LOS for a given patient often tacitly mirror facility billing to be concordant with the professional billing level of service. The concept is that there is often correlation between severity of illness and intensity of services and resource utilization. This may be problematic if the physician group is a high outlier on 99284 and 99285. If the group staffing the ED is not employed, the nursing staff would not be privy to the E&M LOS selected by the provider, and it must choose its own code.

UHC has now indicated it will use the Optum ED Claim Analyzer tool to determine appropriate evaluation and management coding levels. Data such as diagnostic testing, comorbidities and the patient’s presenting problem will be considered by the tool.
UnitedHealthcare listed several exceptions to the policy in its bulletin, including claims for:

  • Admissions from the ED
  • Critical care patients
  • Patients less than 2 years oldCertain diagnoses requiring greater than average resource use when performed in the ED
  • Patients who die in the ED
  • Facilities whose billing of level 4 and 5 E/M codes does not abnormally deviate from Optum’s EDC Analyzer tool determination

The Optum 3D Analyzer takes the sum of three cost categories in reaching a coding decision:

  • Standard Costs
  • Extended Costs
  • Patient Complexity Costs

Step 1: Standard Costs
The EDC Analyzer™ reviews all reasons for visits listed in diagnosis codes and assigns a proportional standard cost allocation (PSCA) and associated standard cost weight to each code based on the age and gender of the patient. If multiple PSCAs are assigned to a claim, the EDC Analyzer™ takes the highest PSCA found. There are five possible PSCAs, corresponding to the five ED visit levels:

Step1of1

PSCA weights were derived from the standard resource valuation for the presenting problems in ED visit level and include the costs associated with the following:

  • Nursing and ancillary staff time (for a routine arrival, triage, registration, basic patient/family communications, and a routine discharge)
  • The room
  • Creation of a medical record
  • Coding and billing

Step2of1

 

Step 2: Extended Costs
The EDC Analyzer™ reviews all line-level services on the claim to identify diagnostic tests that fall into each of the following categories:

  • Laboratory tests
  • X-ray tests (film)
  • EKG/RT/other diagnostic tests
  • CT/MRI/ultrasound tests

Each category carries an extended cost weight. The EDC Analyzer™ adds together the weights for each unique category of tests found on the claim to determine the overall extended cost weight. For example, if two laboratory tests and three X-rays are billed, the EDC Analyzer™ will count the laboratory tests as one and the X-rays as one.
Extended cost weights are calculated for each category based on the level of ED resources expended (including staff time) to create orders, communicate with the patient and staff, and follow up as needed.

Step1of2

Step 3: Patient Complexity Costs
The EDC Analyzer™ reviews all principal and secondary diagnosis codes on the claim, looking for complicating conditions that may impact the level of facility resource utilization. The EDC Analyzer™ then assigns a weight to each complicating diagnosis code that is found. The highest-weighted diagnosis code on the claim is used to determine the overall patient complexity cost weight. If a reason for a visit diagnosis code is billed as a principal or secondary diagnosis code, it is excluded from acting as a complicating condition during this step.

Patient complexity cost weights were developed for each complicating condition by analyzing the additional services typically provided to patients with that complicating condition.
Below are some examples showing how the EDC Analyzer™ assigns a patient complexity cost weight based on a diagnosis code:

Step1of3

Conclusions
The first and most obvious conclusion is that this change will force hospitals to make sure that the coding for complex ED visits will yield the same result as coding using the Optum tool. This is more than just a coding issue. In a coding audit, the reviewer compares the billed codes to the medical record, in addition to the actual billed charges.

Getting the billed claims to meet the requirements of the Optum tool will mean that the chargemaster of each facility must include a crosswalk.

Likely, it will also mean that facilities will have to pay to purchase the Optum tool or pay a consultant that has purchased the tool. Either way, this is potentially a large expense and will require resources from both IT departments and patient financial services area. This increases the ongoing headache of the revenue cycle as other payers like Aetna and Humana likely follow suit with their versions of ER billing requirements.

On my wish list would be that Medicare would publish guidelines for hospital emergency services in the same way that it has for physician services. Considering the current guidelines for physician services have not been updated in 21 years, I am not holding my breath.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Timothy Powell, CPA, CHCP

Timothy Powell is a nationally recognized expert on regulatory matters, including the False Claims Act, Zone Program Integrity Contractor (ZPIC) audits, and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance. He is a member of the RACmonitor editorial board and a national correspondent for Monitor Mondays.

Related Stories

NGS: Please Read Carefully

NGS: Please Read Carefully

It was just a few weeks ago that I apologized in an article focused on contractor misdeeds. The apology was because I prefer to focus

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

This Leap Year, celebrate success with a 29% discount one day ONLY! Use code LEAP24 on February 29th at checkout to unlock this offer! Click here to learn more.
It’s Heart Month! Use code HEART24 at checkout to receive 20% off your cardiology products. Click here to view our suite of Cardiology products!