CurrentUnitedHealthcarePolicy 2025RGOO7B

UB-04 Emergency Department Evaluation and Management (E/M) Level Reimbursement

Defines UnitedHealthcare Medicare Advantage reimbursement methodology for facility UB-04 claims billed with emergency department E/M Level 4 (99284/G0383) and Level 5 (99285/G0384) codes and identifies use of an algorithmic analyzer to determine reimbursable ED visit level for applicable Medicare Advantage plans.

Policy Summary

PayerUnitedHealthcare

PolicyUB-04 Emergency Department Evaluation and Management (E/M) Level Reimbursement

Policy CodePolicy 2025RGOO7B

Change TypeNon‑material revisions

Effective Date

Next Review Date

Key ActionIf you disagree with the EDC Analyzer reimbursement level, follow UnitedHealthcare Medicare Advantage standard reconsideration and appeals processes and resubmit with additional relevant diagnosis codes if omission was the cause.

SourceLink

POLICY UPDATE CHANGES

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

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

Policy created (1/8/2018) and prior history entries archived prior to 9/1/2023.

3factors used by analyzer

6codes listed

9/1/2025most recent history date

Reimbursement Criteria

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ED EIM reimbursement criteria

UnitedHealthcare Medicare Advantage will utilize the Optum EDC Analyzer to determine the EIM level to reimburse for certain facility ED claims. The analyzer uses three algorithmic factors and may adjust or deny submitted Level 4 or 5 codes unless exclusions apply.

ED EIM reimbursement determination is made using the Optum Emergency Department Claim (EDC) Analyzer which calculates a visit level based on three factors.

ALL of the following

Factor 1: Presenting problems as defined by the ICD-10 reason for visit (RFV) diagnosis.
Factor 2: Patient complexity and co-morbidity based on complicating conditions as defined by the ICD-10 principal and secondary diagnosis codes.
Factor 3: Diagnostic services performed measured by the intensity of diagnostic CPT codes submitted on the claim (e.g., lab, X-ray, EKG, other diagnostic, CT/MRI/Ultrasound).

Facilities may experience adjustments to submitted Level 4 (99284/G0383) or Level 5 (99285/G0384) EIM codes to reflect the EDC Analyzer calculated EIM code, or may receive a denial for the code level submitted.

Exclusions — claims that are NOT subject to adjustment/denial include any of the following:

Patient is admitted to inpatient, observation, or has an outpatient surgery during the course of the same ED visit.
Patient is less than 2 years old.
Critical care patients (codes 99291, 99292).
Claims with certain diagnoses that when treated in the ED most often necessitate greater than average resource usage (for example, conditions requiring significant nursing time).
Claims from facilities whose billing of Level 4 and 5 EIM codes does not deviate from the EDC Analyzer.
Patients who expired in the emergency department.

If a facility disagrees with a lower EIM level determined by the EDC Analyzer, the facility may follow UnitedHealthcare Medicare Advantage standard reconsideration and appeals processes; resubmission with additional relevant diagnosis codes may be appropriate if omission of codes was the cause.

This policy applies to UB-04 facility emergency department claims for UnitedHealthcare Medicare Advantage products and may be modified to comply with CMS or coding guideline changes; UnitedHealthcare may apply discretion in applying the policy.

ED E/M Codes and Derived Visit Level

ED E/M and related codesCPT | HCPCS

99284	Emergency department visit, Level 4
99285	Emergency department visit, Level 5
99291	Critical care, evaluation and management
99292	Critical care, additional time
G0383	Hospital outpatient clinic visit — ED equivalent for Level 4
G0384	Hospital outpatient clinic visit — ED equivalent for Level 5

EDC Analyzer — factors and determination of Calculated Visit Level

Presenting problem (ICD-10 RFV)EDC Analyzer uses the ICD-10 reason-for-visit (RFV) code(s) to define the patient’s presenting problem and inform the calculated visit level.

Complicating conditions (ICD-10 principal/secondary diagnoses)Patient complexity and co-morbidity are assessed using ICD-10 principal and secondary diagnosis codes to reflect resource needs.

Diagnostic services intensity (diagnostic CPT codes)The intensity of diagnostic workup (e.g., lab, X‑ray, EKG, CT/MRI, ultrasound) is measured by submitted diagnostic CPT codes and factored into the calculated visit level.

Reconsideration and Appeals

Note

Reconsideration and Appeals

The facility may follow the UnitedHealthcare Medicare Advantage Plan standard reconsideration and appeals processes for administrative claims determinations as outlined in the Administrative Guide. For example, if a facility disagrees with reimbursement at a lower E/M code level than the level submitted (such as level 4 or 5), the facility may use these processes to resubmit the claim with corrected or additional supporting information (for example, adding all relevant and applicable diagnosis codes) that may support the originally billed E/M level.

Facility may use standard reconsideration and appeals for administrative claims determinations (see Administrative Guide).
Use reconsideration/appeals to resubmit claims with updated/corrected diagnosis codes or documentation to support the billed E/M level.
Applicable when facility disagrees with reimbursement at a lower E/M code level than submitted.

Defined Terms

EDC Analyzer — definition and role

Analyzer nameOptum Emergency Department Claim (EDC) Analyzer used by UnitedHealthcare Medicare Advantage to determine reimbursable EIM level for facility ED claims.

FunctionApplies an algorithm to claims data to calculate an EIM visit level that may adjust or deny submitted Level 4 or 5 facility EIM codes.

Inputs usedConsumes presenting problem (ICD-10 RFV), complicating diagnoses (ICD-10 principal/secondary), and diagnostic CPT codes from the UB-04 claim.

EIM level — definition

DefinitionEIM (Emergency department Evaluation and Management) Level refers to the facility E/M visit level (e.g., Level 4 — 99284/G0383; Level 5 — 99285/G0384) used on UB-04 claims for emergency department services.

Basis for assignmentEIM level reimbursement is determined by the intensity of hospital facility resources used during the ED visit and aligned to CMS, CPT and HCPCS coding principles.

Relationship to billingSubmitted facility EIM codes may be adjusted to the EDC Analyzer calculated EIM level or denied if criteria are not met; exclusions apply (e.g., inpatient admission, age <2, critical care).