CurrentUnitedHealthcarePolicy 2026R5007A

CMS-1500 E/M Reimbursement Policy

Defines UnitedHealthcare's reimbursement and documentation expectations for Evaluation and Management (E/M) services billed on the CMS-1500 form for Commercial and Individual Exchange products, and describes when medical records may be requested to support billed E/M levels.

Policy Summary

PayerUnitedHealthcare

PolicyCMS-1500 E/M Reimbursement Policy

Policy CodePolicy 2026R5007A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit accurate CMS-1500 claims and provide medical records upon request when billing patterns or claim attributes indicate possible errors.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form covered

CommercialUnitedHealthcare Commercial scope

Individual ExchangeExchange scope

Time or MDME/M selection

MDM-onlyED codes exception

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Coverage Criteria for E/M Services

Covered when documentation supports selection of the appropriate E/M level based on Time or Medical Decision Making (MDM) per AMA CPT and CMS guidance. UnitedHealthcare may request medical records to ensure the CPT E/M code reported accurately reflects services provided. Providers should follow CPT and CMS documentation guidelines; exceptions and special rules below apply.

ALL of the following

The E/M code reported must accurately reflect the services provided as documented in the medical record and consistent with AMA and CMS documentation guidelines.
Documentation may be requested when billing patterns deviate from peers or claim attributes indicate possible billing errors.
Selection of level of service
- Level of service may be selected based on Time when allowed by CPT (time includes face-to-face and non-face-to-face activities such as examination/evaluation, counseling/education, preparation/review of records/tests, documentation/interpretation, care coordination, orders).
  Do not include time spent by clinical staff, patient wait time, or time for separate distinct procedures provided same day.
- Level of service may be selected based on Medical Decision Making (MDM) where applicable. MDM includes: 1) number and complexity of problems addressed; 2) amount and/or complexity of data reviewed and analyzed (orders for and interpretation of tests/images billed separately cannot be included); 3) risk of complications and/or morbidity or mortality of patient management.
  Two of the three MDM elements must be met or exceeded to select level by MDM.
For Emergency Department codes (CPT 99281-99285) level is determined by MDM only; time is not a component for these codes.
CPT 99281-99285 must be submitted only for services provided in an AMA-defined emergency department (organized hospital-based facility available 24 hours).
Providers may choose either Time or MDM for applicable Office and Outpatient E/M codes (including codes updated Jan 1, 2021 and revisions effective Jan 1, 2023 for specified non-office E/M, consultation, nursing facility, home/residence codes) except where CPT restricts selection method.
See current AMA CPT for detailed requirements for each code series (e.g., 99202-99205, 99211-99215, and revised non-office categories).
When a separate CPT code for a diagnostic test or interpretation/report is billed by the same provider/provider group, that interpretation/report must not be counted toward MDM or reported time for selecting the office or outpatient E/M level.
Per AMA guidance (e.g., CPT 93000 series).
Documentation that appears to be cloned or copied (EHR or hard-copy) is not acceptable to support the billed E/M level.
Includes duplicated HPI, exam, or MDM content produced by copy-paste methods.
If documentation does not support the billed E/M level, UnitedHealthcare may adjust or deny the E/M code; providers may resubmit claims with a revised code for denied claims.
UnitedHealthcare may compare a provider's level escalation and parental narcotic use data to historical and peer data.

E/M Codes and Selection Rules

E/M Codes referencedCPT

99202-99205, 99211-99215	Office and outpatient E/M codes (per CPT/2021 changes)
99221-99223, 99231-99239, 99241-99245, 99252-99255, 99281-99285, 99304-99316, 99341-99350	Non-office, consults, ED, nursing facility, home/residence and related E/M codes (revised 1/1/2023 where noted)

E/M selection rules — Time or MDM

Permitted selection methodsProviders may select E/M level based on Time or Medical Decision Making (MDM).

ED codes exceptionEmergency Department E/M codes 99281-99285 must be determined using MDM only; Time is not used for ED levels.

MDM componentsMDM includes: (1) number and complexity of problems addressed; (2) amount and/or complexity of data reviewed and analyzed; (3) risk of complications and/or morbidity or mortality of patient management.

MDM two-of-three ruleWhen using MDM, two of the three MDM elements for that level must be met or exceeded to support the selected level of service.

Time counting rulesWhen using Time, count qualifying physician/qualified provider face-to-face and non-face-to-face time; exclude clinical staff time, patient wait time, and time for additional distinct procedures performed the same day.

Medical Record Requests and Claim Accuracy — Provider Actions

Documentation Required

Provide medical records on request; ensure claim accuracy

UnitedHealthcare may request medical records when the data indicates a physician or Other Qualified Health Care Professional has a billing pattern that deviates significantly from their peers, or when claim attributes indicate possible billing errors; providers are responsible for submitting accurate claims and must ensure documentation supports the billed E/M level. Documentation that appears to be cloned (copied/pasted) from another record may be unacceptable to support the claim.

Be prepared to provide medical records on request when your billing patterns appear as outliers compared with peers or when claim attributes suggest errors.
Ensure documentation supports the selected E/M level; cloned EHR/hard-copy documentation that replicates information by copy/paste may be unacceptable.
If documentation does not support the billed level, UnitedHealthcare may adjust or deny the claim and providers may need to resubmit corrected claims.

Definitions

Encounter — Definition

DefinitionEncounter — Interaction between a covered member and a health care provider for which evaluation and management service or other service(s) are rendered and results in a claim submission.

ScopeApplies to services billed on the CMS-1500 form under this policy's reimbursement and documentation expectations.

Provider responsibilityProviders are responsible for accurate coding and submission of claims that reflect the services rendered during the encounter.