CurrentUnitedHealthcarePolicy N/A

Evaluation and Management (E/M) services reimbursement

Defines UnitedHealthcare Community Plan Medicaid reimbursement and documentation requirements for CPT Evaluation and Management (E/M) services billed on CMS-1500 or electronic equivalent, and explains how level of service is selected and when records may be requested.

Policy Summary

PayerUnitedHealthcare

PolicyEvaluation and Management (E/M) services reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUnitedHealthcare may request medical records for outlier billing patterns and providers may resubmit denied claims with a revised E/M code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicaidproduct applicability

Time or MDMmethod to select E/M level

Updates 2021, 2023CPT guideline alignment

Record requestdocumentation audit trigger

Evaluation & Management (E/M) Reimbursement Criteria

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 reimbursement and documentation criteria

Covered when ALL of the following documentation and selection rules are met:

Providers may select E/M level based on Time or Medical Decision Making (MDM) for office and outpatient codes (e.g., 99202-99205, 99211-99215); Emergency Department codes 99281-99285 must use only MDM to determine level of care.

Time-based selection: document total time (face-to-face and non-face-to-face) spent on the visit and related activities. Time may include examination/evaluation, counseling/education, preparation for history/test reviews, documentation/interpretation, care coordination/communication with other providers, and orders for tests/procedures/medications.

Time exclusions: do not include time spent by clinical staff, patient wait time, or time for additional distinct service procedures provided the same day as the E/M service.

MDM-based selection: determine MDM by considering (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.

MDM data rule: orders for, and interpretation of, tests or images cannot be counted toward MDM or time when a separate CPT-coded interpretation/report is billed by the same provider/group.

MDM threshold: to select an MDM level, two of the three MDM elements for that level must be met or exceeded.

Risk and surgical package guidance: UnitedHealthcare will use CMS definitions (Pub 100, 40.1) for global surgical package classifications (e.g., codes with '090' considered major surgeries) when assessing risk in MDM.

Emergency Department setting requirement: CPT codes 99281-99285 must only be submitted for services provided in an AMA-defined emergency department (organized hospital-based facility available 24 hours a day), and time is not a descriptive component for ED E/M levels.

Documentation integrity: UnitedHealthcare may request medical records when billing patterns deviate significantly from peers or claim attributes indicate possible errors; documentation that appears cloned (copy-paste) is not acceptable to support the billed level.

Claim resubmission: providers may experience adjustments or denials if documentation does not support the submitted E/M level; denied claims may be resubmitted with a revised E/M code.

Product and billing scope: policy applies to UnitedHealthcare Community Plan Medicaid and to services billed on the CMS-1500 or electronic equivalent across network and non-network providers.

E/M Codes and Medical Decision Making (MDM)

Office and outpatient E/M codesCPT

99202-99205, 99211-99215

Office and outpatient E/M codes (time or MDM selection allowed except 99281-99285 use only MDM)

Non-office E/M visitsCPT

99221-99223, 99231-99239

Non-Office E/M Visits (revised Jan 1, 2023)

Emergency department servicesCPT

99281-99285

Emergency Department Services (use only MDM to determine level)

Nursing facility, home/residence and other selected E/M codesCPT

99304-99316, 99341-99350

Nursing facility, home/residence and other selected E/M codes (revised Jan 1, 2023)

MDM element requirement — two-of-three rule

MDM requirementTwo of the three Medical Decision Making (MDM) elements (1. number/complexity of problems, 2. amount/complexity of data reviewed and analyzed, 3. risk of complications/morbidity or mortality of patient management) must be met or exceeded to select the MDM level.

Data exclusionsOrders for, and interpretation of data from a test or image cannot be included when determining the E/M level if that test or image interpretation is billed separately.

Reference for surgical risk definitionsUnitedHealthcare uses CMS Pub 100 Medicare Claims Processing definitions for surgical package classifications (codes with '090' are major surgeries; '000' or '010' are minor procedures/endoscopies).

Guidance sourceAdditional code selection information and MDM/time requirements are in the most current AMA CPT codebook.

Documentation Requests and Claim Resubmission

Documentation Required

Respond to medical record requests and resubmit denied E/M claims

UnitedHealthcare may request medical records when data show a provider's billing pattern deviates significantly from peers or when claim attributes indicate possible billing errors; if a claim is denied, providers may resubmit the claim with a revised E/M code. Documentation that appears cloned (copied/pasted) from another record will not be acceptable to support the claim as billed.

Provide requested medical records promptly when UnitedHealthcare flags outlier billing patterns or suspicious claim attributes.
If a claim is denied for coding/documentation issues, resubmit with a corrected E/M code as appropriate.
Ensure EHR documentation is original and not cloned; copied or pasted history, exam, or MDM entries may be deemed unacceptable.

OpenPayer

Evaluation and Management (E/M) services reimbursement

Evaluation & Management (E/M) Reimbursement Criteria

E/M Codes and Medical Decision Making (MDM)

Documentation Requests and Claim Resubmission

Key Definitions