CurrentColorado Rocky Mountain Health PlansPolicy 2025R6007B

Emergency Department UB-04 E/M Level Reimbursement

Defines how UnitedHealthcare Medicare Advantage reimburses facility UB-04 claims for emergency department Evaluation and Management (E/M) Level 4 and 5 services and describes use of an automated analyzer to determine payable E/M level; applies to Medicare Advantage facilities billing on UB-04.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEmergency Department UB-04 E/M Level Reimbursement

Policy CodePolicy 2025R6007B

Change TypeOperational / Administrative updates

Effective Date

Next Review Date

Key ActionIf a facility disagrees with a lowered E/M reimbursement, follow UnitedHealthcare Medicare Advantage standard reconsideration and appeals processes and resubmit with additional diagnosis codes if appropriate.

SourceLink

POLICY UPDATE CHANGES

EDC Analyzer URL updated in Reimbursement Guidelines and Questions and Answers sections.

Policy Application section updated (9/1/2024).

Entries prior to 9/1/2023 archived in policy history.

6codes listed in Codes section

3factors used by the EDC Analyzer to calculate visit level

6criteria examples that may exclude claims from adjustment

All

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Emergency Department E/M Reimbursement Criteria

ED E/M Reimbursement Criteria

UnitedHealthcare Medicare Advantage will reimburse emergency department (ED) facility E/M codes but may use the Optum EDC Analyzer to determine the payable facility E/M level. Certain claims are excluded from adjustment.

UnitedHealthcare Medicare Advantage will reimburse facility ED E/M codes billed on UB-04, but may apply the Optum Emergency Department Claim (EDC) Analyzer to determine the Calculated Visit Level for reimbursement.

ALL of the following

Presenting problems as defined by the ICD-10 reason for visit (RFV) diagnosis.
Diagnostic services performed based on intensity of the diagnostic workup, measured by diagnostic CPT codes submitted on the claim (e.g., lab, X-ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound).
Patient complexity and co-morbidity based on complicating conditions as defined by the ICD-10 principal and secondary diagnosis codes.

Facilities may receive an adjustment to the submitted Level 4 or 5 ED E/M code to match the EDC Analyzer Calculated Visit Level, or a denial for the submitted level.

Claims excluded from adjustment include

Patient admitted to inpatient, observation, or has an outpatient surgery during the same ED visit.
Critical care services were provided (e.g., CPT 99291, 99292).
Patient is less than 2 years old.
Diagnosis that typically necessitates greater-than-average resource usage when treated in the ED (for example, conditions requiring significant nursing time).
Patient expired in the emergency department.
Claims from facilities whose historical billing of Level 4 and 5 E/M codes does not deviate from the EDC Analyzer results (i.e., facility billing consistent with the Analyzer).

If a facility disagrees with a lowered E/M reimbursement, follow UnitedHealthcare Medicare Advantage standard reconsideration and appeals processes for administrative claims determinations; facilities may resubmit with additional relevant diagnosis codes if appropriate.

Codes and EDC Analyzer Visit Level

Emergency Department Facility E/M and related codesCPTCovered

99284	ED E/M Level 4
99285	ED E/M Level 5
G0383	Facility ED visit, Level 4
G0384	Facility ED visit, Level 5
99291	Critical care, first 30-74 minutes
99292	Critical care, each additional 30 minutes

EDC Analyzer Calculated Visit Level

DefinitionAlgorithm-derived level based on three factors: presenting problems (ICD-10 RFV), diagnostic services billed (diagnostic CPT codes), and patient complexity/co-morbidity (ICD-10 principal and secondary diagnosis codes).

PurposeUsed by UnitedHealthcare Medicare Advantage to determine the payable emergency department E/M level for facility UB-04 claims.

OutcomeFacilities may receive an adjustment to submitted Level 4 or 5 E/M codes to match the EDC Analyzer Calculated Visit Level or a denial for the submitted level.

Appeals, Reconsideration, and Claim Adjustment Actions

Prior Authorization

Reconsideration and Appeals — follow standard Medicare Advantage processes

If your facility disagrees with a lowered E/M reimbursement, follow UnitedHealthcare Medicare Advantage’s standard reconsideration and appeals processes for administrative claims determinations. Resubmit the claim with additional relevant diagnosis codes if the original submission omitted applicable diagnoses that support the submitted Level 4 or 5 E/M code.

Use the Plan’s administrative guide to initiate reconsideration and appeals.
Resubmit with appropriate additional diagnosis codes when applicable to support the originally billed E/M level.

Billing Rule

Potential Claim Adjustment or Denial based on EDC Analyzer Calculated Level

Facilities may have submitted Level 4 or 5 E/M codes adjusted to the EDC Analyzer–calculated level or receive denials for the submitted level; ensure claims include complete diagnostic services and diagnosis codes as billed so the Analyzer has all inputs used to calculate the payable level.

Definitions and Facility Coding Guidance

Optum Emergency Department Claim (EDC) Analyzer

Tool nameOptum Emergency Department Claim (EDC) Analyzer — an algorithmic tool that calculates an emergency department E/M level using presenting problems, diagnostic services, and patient complexity.

InputsPresenting problems (ICD-10 reason for visit), diagnostic CPT codes for tests/procedures, and ICD-10 diagnosis codes indicating patient complexity/co-morbidity.

Use in policyUnitedHealthcare Medicare Advantage will utilize the EDC Analyzer to determine the ED E/M level to be reimbursed for certain facility claims billed on UB-04.

Facility coding focus

Primary principleFacility coding should be based on hospital facility resources and not physician resources, and should follow the intent of the CPT code descriptor.

Objective