CurrentColorado Rocky Mountain Health PlansPolicy 2026R5007A

CMS 1500 E/M Reimbursement Policy

Defines UnitedHealthcare reimbursement and documentation requirements for Evaluation and Management (E/M) services billed on the CMS-1500 form for Commercial and Individual Exchange products and applies to network and non-network physicians and other qualified health care professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCMS 1500 E/M Reimbursement Policy

Policy CodePolicy 2026R5007A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders may be asked to submit medical records and may resubmit claims with revised E/M codes if documentation does not support the originally billed level.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500form coverage

2021 & 2023code update refs

Commercial & Exchangeproduct applicability

audit riskaudit trigger

Evaluation & Management Coverage Criteria

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E/M coding and documentation criteria

Covered when ALL of the following criteria are met:

ALL of the following

E/M level selection
- Time-based selection: Total time may be used to select the E/M level and may include face-to-face and non-face-to-face activities such as examination/evaluation, counseling/education, prep time for history/test review, documentation/interpretation, care coordination/communication with other providers, and orders for tests/procedures/medication; time excludes clinical staff time, patient wait time, and additional distinct same-day procedures.
- MDM-based selection: MDM is determined by three elements: (1) number and complexity of problems addressed, (2) amount and/or complexity of data reviewed and analyzed, and (3) risk of complications and/or morbidity or mortality of patient management; two of the three elements must be met or exceeded to select a level by MDM; orders for and interpretation of tests billed separately cannot be counted in the data element.
ED visits: For emergency department visits, CPT codes 99281-99285 must be used and level is determined by MDM only; these codes must be submitted only for services provided in an emergency department as defined by AMA CPT (organized hospital-based facility available 24 hours a day).
Documentation & audit: UnitedHealthcare may request medical records when billing patterns deviate significantly from peers or claim attributes indicate possible billing errors; documentation that appears cloned from other records (including EHR templates copied/pasted) is not acceptable to support the billed claim.
Claim resubmission: If a claim is denied because documentation does not support the originally billed E/M level, providers may resubmit the claim with a revised E/M code supported by the documentation.

Operational note: See AMA CPT codebook for additional details on Time and MDM definitions and level requirements.

Codes, Time and MDM Selection Rules

E/M code sets and rulesCPTCovered

99202-99205, 99211-99215	Office/outpatient E/M codes usable with Time or MDM (post-2021 changes)
99221-99223, 99231-99239, 99242-99245, 99252-99255, 99281-99285, 99304-99316, 99341-99350	Non-office, consults, ED, nursing facility, home/residence codes revised Jan 1, 2023 (except ED uses MDM only)

Policy-specific code listCPT

Evaluation and Management Procedure Code List

Crosswalk-style list included in policy (see policy for full list)

Time-based selection — Key rules

Permitted selectionProviders may select the E/M level based on total time (face-to-face or non-face-to-face).

Included activitiesTime may include examination/evaluation, counseling/education, prep for history/test review, documentation/interpretation, care coordination/communication, and orders for tests/procedures/medication.

Excluded activitiesTime spent by clinical staff, patient wait time for the physician or other health care providers, and time for additional distinct same-day procedures are excluded.

MDM-based selection — Key rules

MDM element ruleWhen using Medical Decision Making (MDM), two of the three elements (number/complexity of problems; amount/complexity of data reviewed and analyzed; risk of complications and/or morbidity or mortality of patient management) must be met or exceeded.

Data element limitationOrders for and interpretation of data from a test or image cannot be included in the data element when the test or image interpretation is billed separately.

ED exceptionEmergency department E/M codes (99281-99285) use MDM only; time is not a descriptive component for ED E/M levels.

Documentation, Records Requests, and ED Coding

Documentation Required

Medical record requests and claim resubmission

UnitedHealthcare may request medical records when a provider's billing pattern deviates significantly from peers or when claim attributes indicate possible billing errors; providers may resubmit a claim with a revised E/M code for denied claims when documentation does not support the originally billed level.

Records are not requested for all E/M services — requests occur when data indicate atypical billing patterns or possible errors.
If a claim is denied because documentation does not support the billed E/M level, the provider may resubmit the claim with a revised E/M code.

Billing Rule

ED coding restriction — use CPT 99281–99285 for ED visits

Emergency department visits must be reported using CPT codes 99281–99285 and those codes may only be submitted for services provided in an emergency department as defined by AMA CPT; time is not a descriptive component for ED E/M levels.

ED E/M codes 99281–99285 apply to both new and established patients for services rendered in an ED.
If documentation does not support the ED or other E/M level submitted, the provider may experience adjustments or denials and may resubmit with a revised E/M code.

Key Definitions

Encounter — Definition and implications

DefinitionEncounter: Interaction between a covered member and a health care provider resulting in an E/M or other service and a claim submission.

PurposeUsed to identify events that generate CMS-1500 billing and may trigger medical record review for reimbursement validation.

Documentation implicationAn encounter's documentation should support the E/M code(s) billed to accurately describe services provided.

Evaluation and Management (E/M) — Definition

DefinitionEvaluation and Management (E/M): CPT E/M categories describe service type, place of service, patient status, and documentation requirements used to determine the appropriate CPT E/M code.

ImportanceClassification affects expected provider work, documentation required, and appropriate reimbursement level.

Guidance sourceCode selection and documentation expectations follow AMA and CMS documentation guidelines as described in the CPT codebook and this policy.