CurrentUnitedHealthcarePolicy 2025R5007A

Evaluation and Management (E/M) services reimbursement on CMS 1500

Governs UnitedHealthcare Medicare Advantage reimbursement and documentation requirements for Evaluation and Management (E/M) services billed on CMS 1500 forms; affects providers submitting claims to UnitedHealthcare Medicare Advantage plans.

Policy Summary

PayerUnitedHealthcare

PolicyEvaluation and Management (E/M) services reimbursement on CMS 1500

Policy CodePolicy 2025R5007A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvide accurate medical records and supporting documentation when requested, and resubmit claims with a revised E/M code if denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Covers CPT E/M rangesE/M code groups addressed

Uses Time or MDMTime or MDM option

May request recordsRecord requests possible

Jan 1, 2021 & 2023CPT guideline dates

2016–2025Policy history

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

E/M Selection and Documentation Criteria

E/M selection and documentation criteria

Covered when ALL of the following are met:

Providers must select E/M codes that best represent services provided per AMA and CMS documentation guidelines.

For office and outpatient E/M codes (e.g., 99202-99205, 99211-99215) and most other E/M codes, the provider may choose the appropriate E/M level based on Time or Medical Decision Making (MDM).

Emergency Department E/M codes (99281-99285) must be selected based on MDM only; Time is not a component for ED E/M levels.

When using Time to select level of service, documented time may include face-to-face and non–face-to-face activities such as examination/evaluation, counseling/education, preparation for patient history/test review, documentation/interpretation, and care coordination; time must NOT include clinical staff time, patient wait time, or additional distinct procedures performed the same day as the E/M service.

When using MDM, two of the three MDM elements (1. number/complexity of problems addressed; 2. amount/complexity of data reviewed and analyzed; 3. risk of complications and/or morbidity or mortality of patient management) must be met or exceeded.

Orders for, and interpretation of, tests or images that are billed and reported separately should not be counted in the MDM data element or included in time calculations for E/M selection.

Documentation that appears cloned (copy-paste) is not acceptable to support the billed E/M level; documentation from EHR or hard-copy that appears replicated from another record will not support the claim as billed.

UnitedHealthcare Medicare Advantage may request medical records when a provider's billing patterns deviate significantly from peers or claim attributes indicate possible billing errors; denied claims may be resubmitted with a revised E/M code when appropriate.

Referenced Codes and Coding Rules

Referenced E/M CPT code groupsCPTCovered

99202-99205, 99211-99215	Office and outpatient E/M codes (2021 guideline alignment)
99221-99223, 99231-99239	Non-office E/M visits revised Jan 1, 2023
99281-99285	Emergency Department services — MDM only
99304-99310, 99315-99316	Nursing facility services
99341-99342, 99344-99345, 99347-99350	Home or residence visits

Time vs MDM selection — applicable rules

Selection optionsProviders may document E/M level using Time or Medical Decision Making (MDM); Time criteria include face-to-face and non-face-to-face activities such as examination/evaluation, counseling/education, preparation for history/test review, documentation/interpretation, care coordination/communication, and orders for tests/procedures/medication; Time does not include clinical staff time, patient wait time, or additional distinct procedures provided the same day.

Exception — Emergency Department (ED) codesED E/M codes (99281-99285) must be selected based on MDM only; time is not a component for ED E/M levels.

Reference guidanceCode selection based on Time or MDM and requirements are per the current AMA CPT codebook.

Prohibited inclusions for Time/MDMTime may not include clinical staff time or patient wait time; orders for and interpretation of tests/images billed separately cannot be included in the MDM data element.

Provider Responsibilities and Record Requests

Documentation Required

Medical record requests and provider responsibility

UnitedHealthcare Medicare Advantage may request medical records when billing data show a provider's billing pattern deviates significantly from peers or when claim attributes indicate possible billing errors. Providers are responsible for submitting accurate claims and must retain and produce supporting medical records when requested. Documentation that appears cloned (copy‑paste) is not acceptable to support the billed E/M level.

UnitedHealthcare may request records when billing patterns deviate from peers or claim attributes indicate possible billing errors.
Providers are responsible for accurate claim submission and must provide medical records upon request.
Cloned documentation (copied/pasted content) is unacceptable to support the billed E/M level.

Key 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.

Context of useAn encounter is the recognized event for which providers bill E/M or other services on the CMS 1500 form.

Documentation requirementMedical record documentation of the encounter is required to support the billed E/M level.

Medical Decision Making (MDM) — components and rule

MDM elementsMDM is composed of three elements: (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.

Requirement to meet level