Three key takeaways from this effort by healthcare giant UnitedHealthcare

UnitedHealthcare (UHC) is continuing its quest to revamp many facets of our healthcare industry. Last year, they adapted mandatory policies for the use of the SA modifier to indicate that a professional service was performed as incident-to, and now the company is introducing a mandatory review of high-level ED facility-based service codes.

The newest UHC policy took effect March 1 and applies to both UHC’s commercial plans and its Medicare Advantage plans, as well as claims submitted to UHC from non-participating facilities.

Organizations that submit claims to UHC have begun to see a dramatic change in coding policy, with emergency department (ED) service codes of Level 4 and 5 now undergoing review for adjustment or outright denial.

Let’s review the policy change and the explanation posted by UHC, and then we will walk through concerns providers have including the following:

Simply selecting ED codes 99284 and 99285, which represent moderate-complexity and high-complexity cases, will result in the claim being reviewed by UHC using its Optum Emergency Department Claim (EDC) Analyzer tool, which is a software module that supposedly “systematically evaluates each ED visit level code in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender) to ensure that it reasonably relates to the intensity of hospital resource utilization as required per CMS (Centers for Medicare & Medicaid Services) guidelines.”

UHC stated in its December 2017 bulletin, that the other ED codes, 99281-99283 (in the same family of codes) will not be subject to this automatic review by the EDC tool. UHC further stated that those facilities submitting claims with 99284 or 99285 will have those claims “adjusted” in level, which is to say downcoded, or completely denied, based on “the reimbursement structure within their agreements with UnitedHealthcare,”.

There are some exceptions to the automatic EDC review, which include:

  • Admissions from the ED;
  • Critical care patients;
  • Patients younger than 2 years of age;
  • Certain diagnoses requiring greater-than-average resource use when performed in the ED;
  • Patients who die in the ED; and
  • Facilities whose billing of Level 4 and 5 evaluation and management (E&M) codes does not abnormally deviate from Optum’s EDC Analyzer tool determination.

Facilities that see either a reduction in their ED code levels or denials will be able to submit reconsideration or appeal requests if they disagree with the EDC analyzer’s findings and the subsequent “adjustments,” according to the UHC bulletin. The massive increase in scrutiny created by this new policy is needed, UHC said, to “support UnitedHealthcare’s commitment to the triple aim of improving healthcare services, health outcomes, and overall cost of care.”

 Now, let’s break it all down:

 Facility coding guidelines are different from professional coding guidelines. Therefore, although the codes used to bill and support the facility-based services are the same, the utilization of these codes are quite different. When reported for Facility services codes are chosen based on the volume and intensity of resources utilized by the facility to provide patient care. In fact, while physicians pay homage to documentation guidelines with every single service they provide, CMS has yet to create a standard by which facility ED codes are applied to an encounter.

ACEP has created a set of standards than many ED’s across the country have adopted, and therefore has become somewhat of an industry standard, but again- previously no formal process has been adapted. Therefore, many would stay that there is no definitive correlation between facility and professional coding and therefore no rational basis for the application of one set of codes for the determination of the other on a case-by-case basis.  However, when we begin to review the steps the EDC analyzer will evaluate the line between facility services, and the professional use of the code set begins to get lost in the sand.

According to the EDC analyzer (, Step one is a consideration of the level of risk of the patient’s presenting problem to drive the standard resource valuation for the presenting problems in that ED visit level and include the costs associated with the following:

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

These four resource valuations are driven by the risk associated with the patient’s presenting problem as referenced within the MDM scoring process for professional based services. So, while these coding systems are supposed to be different, we begin to see how the facility service is also driven by the complexity of care of the patient identifying their stated medical necessity. While medical necessity should be the determination of what is billed and why it should be reimbursed, the problem in UHC’s step one determination is the initial weighted costs related to the presenting problem.

For clarity, this methodology is better explained with an example. The weight of a patient presenting for a blood pressure check may seem anteriorly low, but if their blood pressure is severely high, then our presenting problem just increased 1-2 levels to a higher level of severity, which depending on the severity may pose imminent threat to support the highest cost weight category.

Step two within the EDC provides for a review of all line-level services on the claim to identify diagnostic tests as follows: 

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

Consideration was allowed to provide for costs of creating orders, time and staffing to provide the testing, and communication with the patient. These cost weights are then added together per each category to find the total weighted consideration. WOW, this sounds much like the data and complexity section of MDM scoring of professional services but extending them beyond the scope of the physician service and realizing the facility burden associated with each category of service.

Step 3 will then take into all diagnoses assigned to the patient that may impact utilization of resources based on complicating factors, i.e., the risk imposed by the patients care level needed. UHC has indicated that they have Patient complexity cost weights that were developed for each complicating condition by analyzing the additional services typically provided to patients with that complicating condition. UHC provides examples of diagnoses and conditions that they have weighted. However, they do not provide the weighted costs associated with each.

UHC’s final step, once again, sounds suspiciously comparative to professional services as we will use the 3 categories to assess our service collectively. The formula they have published is the following:

Total Weight = Standard Cost Weight (Step 1) + Extended Cost Weight (Step 2) + Patient Complexity Cost Weight (Step 3)

Pricing = resources required based on presenting problem + resources expended based on Categories of service used + the potential resources consumed based on the diagnoses of the encounter

There is one curiosity that the EDC by UHC does not indicate and that is the weighted cost of each step. This information has been redacted from their website and not published, and therefore we do not know exactly the scoring process that has been implemented. At least on the professional services side, the scoring process of the medical decision making (MDM) —again comparative in nature— does provide us with the guidance of the weight of each element to support the overall service. However, UHC has chosen to keep this information confidential.

So let’s apply this to a condition. There are two words that when put together, escalate care in the ED: chest pain. I do realize that facilities have protocol requirements for this type of scenario, but before we engage in a debate, please be reminded that is a facility’s protocol and not the carrier’s. Unless the medical necessity can support the appropriateness of the services rendered, the carrier may decline reimbursements.

However, let’s proceed. Patient reports to the ED for chest pain and of course lab, radiology, and diagnostic testing is performed, but ultimately it is determined that the patient’s problem is merely heartburn and they are discharged to home. The UHC EDC would consider our formula as follows:

Remember your algebra rules for this one:

Total Weight = Chest pain + (lab + Radiology + EKG) + GERD

Pricing = Extensive resources needed for chest pain presenting problem + 3 categories of service line resources + a lower resource consuming formal diagnosis of the encounter

In conclusion, three final points:

  • Industry Modeling: UHC has created a “scoring methodology” through what they consider an analytics program, but what it really seems like is they have tried to use E&M Documentation Guidelines for Professional Services to create an industry modeling scoring of these facility-based services. Now come on, everyone knows how gray and ambiguous E&M Guidelines are, and let’s get serious… the MDM is one of the MOST troublesome parts! Therefore, it seems this may end up causing more confusion as opposed to providing valued guidance.
  • UHC Mandatory Automatic Reviews: This policy has provided some basis for facilities to better apply the proper ED service code, but it will likely raise overhead expenses on both sides. As we pointed out through this article, much of this scoring process is based on MDM related scoring principals which are gray and ambiguous at best and part of Marshfield Guidelines, which “technically” have never been formally adopted as part of the official guidelines. Now facilities will be required to produce proof to substantiate every single level 4 and 5 encounter through an appeal process. Additionally, UHC is now going to have to review every single appealed encounter. Who loses? Patients! This increased overhead will affect them on both sides: as a consumer and an insured.
  • Data Analytics Reviews: It’s the new buzz-phrase in healthcare. Not only has data analytics created new avenues in which carriers can track all services by facilities and providers, but more importanty, facilities and providers can now analyze their own risk and focus on their compliance dollars. However, analytics cannot assess medical necessity regardless of the type of service- be it facility or professional. Keep in mind that UHC essentially has an algorithm that raises red flags of alert, but that should only be a flag, as it truly takes a reviewer to analyze services for medical necessity.

Is the point of this policy to encourage undercoding? Maybe, but rather than point fingers in this way, let’s ponder for just a moment what this policy still does not do. It does not provide an avenue to educate the masses on the proper use of these codes. Instead, this policy will increase labor by driving unnecessary medical reviews.

We need the carriers to back educational efforts to help improve code usage, rather than introducing burdensome policies that increase healthcare costs to all involved.

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Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

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