By: Pamela Bensen, MD, MS, FACEP

Emergency departments (EDs), the US healthcare system “safety net”, are seeing sicker patients as the “less sick” are routed to offices and urgent care. This concentration of complicated patients requiring more extensive workups and treatments has increased the percentage of Evaluation and Management (E/M) level 4 and 5 visits.

UnitedHealthcare (UHC), whose stock has gone up 1000% since 2010, conducts ED coding, documentation, and claim reviews via its wholly owned subsidiary, Optum Payment Integrity. Despite appropriate documentation to support the complexity of the E/M codes submitted, Optum denies payment for ED services. Written appeals that support the original code(s) are almost universally denied, with UHC refusing to pay for ED services, or paying the claim at a reduced level.

Denials are due to Optum’s software algorithms that use the final ED ICD-10-CM diagnosis codes to determine the E/M code. However, the AMA’s Current Procedural Terminology (CPT Manual) and the CMS 1995 Documentation Guidelines for Evaluation and Management Services (DGs) clearly direct that determination of the proper E/M code for emergency medicine encounters is not based on the ICD-10-CM code, but instead requires a combination of three key components:
• History
• Physical Exam
• and Medical Decision Making

And, the level of each of these key components should only be based on the Medical Decision Making defined as, “the complexity of establishing a diagnosis and/or selecting a management option as measured by”:
1. Number of possible diagnoses/management options considered;
2. Amount/complexity of medical records, diagnostic tests, other information reviewed and analyzed; and
3. Risk or significant complications, morbidity, mortality, and comorbidities, associated with the patient’s presenting problem(s), diagnostic procedure(s) or possible management options.

After a four year battle, in a September 16, 2019 letter (read original here), the American College of Emergency Physicians (ACEP), representing 40,000 emergency physicians, and the Emergency Department Practice Management Association (EDPMA), representing about half of the 146 million patient visits to US EDs, notified UHC that they are advising their members that all necessary and appropriate legal action should be considered, including litigation addressing non-payment for services rendered. Copies were sent to federal and state officials and U.S. Senators and Representatives.

Resources

State PLP laws that apply to state regulated health plans. For additional information visit: http://newsroom.acep.org/2017-06-09-prudent-layperson-standard

CMS letter from April 2000 clarifying the definition of PLP in the BBA of 1997: https://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd040500.pdf

Federal Register Nov. 10, 1999 (Vol 64, No. 217)  page 166 link

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