CurrentUnitedHealthcarePolicy 2025R6003A

UB04 Emergency Department facility E/M (Levels 4 and 5) reimbursement

Defines UnitedHealthcare's reimbursement approach for emergency department facility claims billed on UB04 forms (levels 4 and 5 E/M) for network and non-network hospital and free-standing emergency departments.

Policy Summary

PayerUnitedHealthcare

PolicyUB04 Emergency Department facility E/M reimbursement (levels 4 and 5)

Policy CodePolicy 2025R6003A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionIf relevant diagnosis or procedure codes were omitted, resubmit a corrected claim or follow standard reconsideration and appeals processes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 factorsEDC inputs

6 examplesExclusions

UB04Claim form

99284/99285E/M levels

Emergency Department Facility E/M Reimbursement Criteria

ED E/M reimbursement criteria

UnitedHealthcare will reimburse emergency department (ED) facility E/M codes but may adjust or deny billed level 4 or 5 codes based on the Optum Emergency Department Claim (EDC) Analyzer. Certain claim types and situations are excluded from adjustment.

EDC Analyzer application: UnitedHealthcare may use the Optum Emergency Department Claim (EDC) Analyzer to determine a Calculated Visit Level for ED facility E/M services; the algorithm considers presenting problems (ICD-10 RFV), diagnostic services performed (diagnostic CPT codes on the claim), and patient complexity/co-morbidity (ICD-10 principal, secondary, and external cause codes).

Calculated Visit Level may be used to adjust reimbursement for submitted level 4 (99284/G0383) or level 5 (99285/G0384) facility E/M codes.

EXCLUSIONS — claim types or situations that are NOT subject to adjustment

Patient is admitted to inpatient, has an outpatient surgery during the same ED visit, or is discharged/transferred to another health care institution.
Claim includes critical care services (CPT 99291 or 99292).

Policy Summary

PayerUnitedHealthcare

PolicyUB04 Emergency Department facility E/M reimbursement (levels 4 and 5)

Policy CodePolicy 2025R6003A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionIf relevant diagnosis or procedure codes were omitted, resubmit a corrected claim or follow standard reconsideration and appeals processes.

SourceLink

On This Page

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.

Applicable Codes and Algorithm Inputs

Emergency department facility E/M codesCPTCovered

99284	ED E/M Level 4 (facility)
99285	ED E/M Level 5 (facility)
G0383	CMS HCPCS equivalent for ED Level 4
G0384	CMS HCPCS equivalent for ED Level 5

EDC Analyzer calculated level — algorithm inputs

Algorithm inputsEDC Analyzer uses three factors to calculate a Calculated Visit Level: presenting problems (ICD-10 reason for visit), diagnostic services performed (diagnostic CPT codes such as lab, X‑ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound), and patient complexity/co‑morbidities (ICD‑10 principal, secondary, and external cause codes).

PurposeDetermines the emergency department E/M level used by UnitedHealthcare to reimburse certain facility ED claims; may result in adjustments or denials of billed level 4/5 codes.

Data sourcesUses diagnosis codes (ICD‑10 RFV and other ICD‑10 diagnoses) and submitted diagnostic CPT codes from the UB04 claim to measure presenting problem, diagnostic intensity, and complexity.

Impact on reimbursementIf EDC Analyzer calculates a lower E/M level than billed (99284/G0383 or 99285/G0384), the facility may receive an adjustment or denial; UnitedHealthcare may estimate reimbursement and allow resubmission of an adjusted claim.

Billing, Resubmission, and Appeal Actions for Facilities

Prior Authorization

Corrected claim / appeals

If a facility identifies that the original claim omitted relevant diagnosis or procedure codes that could support the level of E/M originally billed, the facility may submit a corrected (resubmitted) claim with the appropriate codes. Alternatively, facilities may pursue UnitedHealthcare’s standard reconsideration and appeals processes for administrative claim determinations as described in the UnitedHealthcare administrative guide if they disagree with the reimbursement determination.

Corrected claim resubmission: add any omitted relevant ICD-10 or CPT/HCPCS codes that support the originally billed E/M level.
Appeals / reconsideration: follow UnitedHealthcare standard reconsideration and appeal procedures per the administrative guide if you disagree with the EDC Analyzer outcome or claim adjudication.
If UnitedHealthcare provided an estimated reimbursement for an adjusted level 4 or 5 E/M code based on historical experience, facilities may resubmit an adjusted claim; UnitedHealthcare will adjudicate the resubmitted claim based on the new charges in accordance with this policy.

Definitions and Coding Principles

CMS facility coding principles

Facility focusFacility coding should be based on hospital facility resources (not physician resources) and relate the intensity of hospital resources to the different E/M code levels.

Coding intentFollow the intent of the CPT code descriptor and design guidelines to reasonably relate resource intensity to levels of effort represented by the code.

Anti‑upcodingPrinciples should not facilitate upcoding or gaming; facilities are expected to bill differentially for outpatient visits, including ED visits.

EDC Analyzer — definition and description

Scope of useUnitedHealthcare utilizes the EDC Analyzer to determine the ED E/M level to be reimbursed for certain facility UB04 claims, particularly for billed level 4 and 5 codes.

Outcome possibilitiesThe Analyzer may produce a lower calculated E/M level leading to adjustment of reimbursement or denial of the submitted level; facilities may resubmit adjusted claims if applicable.