CurrentUnitedHealthcarePolicy 2025R6007B

UnitedHealthcare Medicare Advantage Reimbursement Policy — UB-04 ED Facility E/M (EDC Analyzer)

Defines UnitedHealthcare Medicare Advantage reimbursement methodology for UB-04 emergency department facility E/M Level 4 (99284/G0383) and Level 5 (99285/G0384) claims, including use of an algorithmic analyzer to determine reimbursable E/M level; applies to Medicare Advantage plans and facilities billing UB04 forms.

Policy Summary

PayerUnitedHealthcare

PolicyUB-04 ED Facility E/M reimbursement using EDC Analyzer

Policy CodePolicy 2025R6007B

Change TypeNon-material updates (URLs, application text)

Effective DateJan 1, 2025

Next Review Date

Key ActionFacilities may follow UnitedHealthcare Medicare Advantage standard reconsideration and appeals processes and may resubmit with additional diagnosis codes if they disagree with an adjusted reimbursement level.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Guidelines: EDC Analyzer URL Updated

Questions and Answers: EDC Analyzer URL Updated

Policy Application Section: Updated

3factors used by EDC Analyzer

2E/M facility levels described

6exclusion criteria examples

1external analyzer referenced

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EDC Analyzer Reimbursement Criteria

EDC Analyzer reimbursement criteria

UnitedHealthcare Medicare Advantage will utilize the Optum Emergency Department Claim (EDC) Analyzer to determine the reimbursable ED E/M level for certain facility UB‑04 claims. Covered when ALL of the following apply unless an exclusion below is met:

EDC Analyzer determination applies to facility UB-04 claims submitted with ED E/M Level 4 (99284/G0383) or Level 5 (99285/G0384).

Facilities may experience an adjustment of the submitted Level 4 or 5 to the EDC Analyzer-calculated E/M level or may receive a denial for the submitted level.

EXCLUSIONS - Claims are NOT subject to Analyzer adjustment or denial if ANY of the following apply

Patient admitted to inpatient, observation, or has an outpatient surgery during the same ED visit.
Claim includes critical care services (e.g., CPT 99291, 99292).
Patient is less than 2 years of age.
Claim has certain diagnoses that typically require greater-than-average resources when treated in the ED (for example, diagnoses necessitating significant nursing time).
Patient expired in the emergency department during that visit.
Facility billing patterns for Level 4 and 5 E/M codes do not deviate from the EDC Analyzer (i.e., facility billing aligns with Analyzer expectations).

If a facility disagrees with an adjusted or reduced reimbursed level, the facility may follow UnitedHealthcare Medicare Advantage standard reconsideration and appeals processes for administrative claims determinations; resubmission with additional diagnosis codes may be used to support the originally billed level.

ED Facility E/M Codes and Calculated Visit Level

ED facility E/M codesCPTCovered

99284	ED visit, level 4 (facility billing)
99285	ED visit, level 5 (facility billing)
G0383	Hospital outpatient clinic visit level 4 (HCPCS crosswalk)
G0384	Hospital outpatient clinic visit level 5 (HCPCS crosswalk)

EDC Analyzer calculated visit level

Calculated visit level — primary factorsPresenting problem (ICD-10 reason for visit), diagnostic services performed (diagnostic CPT codes for labs, X‑ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound), and patient complexity/co‑morbidity (ICD‑10 principal and secondary diagnoses)

Potential outcomesSubmitted facility Level 4 or 5 E/M may be adjusted to the Analyzer‑calculated level or denied for the submitted level

Exclusions from adjustmentClaims where patient admitted to inpatient/observation or has outpatient surgery during same ED visit are excluded

Other exclusionsCritical care (99291, 99292), patients under 2 years, patients who expired in the ED, and claims with certain high‑resource diagnoses may be excluded

Operational noteAnalyzer uses intensity of diagnostic workup as measured by submitted diagnostic CPT codes

Appeals, Reconsideration, and Provider Next Steps

Prior Authorization

Appeals and Reconsideration — Provider Actions

The facility may follow UnitedHealthcare Medicare Advantage Plan standard reconsideration and appeals processes for administrative claims determinations as outlined in the administrative guide. For example, if the facility disagrees with a reimbursement decision that reduced an Emergency Department E/M code from the submitted level (e.g., level 4 or 5) to a lower level, the facility may use the reconsideration and appeals processes to resubmit the claim with corrected or additional information (such as all relevant and applicable diagnosis codes) that could support the originally billed E/M level.

If claim was denied or adjusted due to missing or incomplete diagnosis codes, resubmit with appropriate diagnosis codes via the standard reconsideration/appeals process.
Follow the UnitedHealthcare Medicare Advantage administrative guide for timelines, required documentation, and submission steps for reconsideration and appeals.
These processes apply to administrative claims determinations (billing/reimbursement issues), not clinical determinations.
Applicable to all emergency departments (facility-based, free-standing, or otherwise) when seeking administrative reconsideration for E/M level disputes.

Key Definitions and Coding Principles

Optum Emergency Department Claim (EDC) Analyzer

DefinitionOptum Emergency Department Claim (EDC) Analyzer — an algorithmic tool that determines a Calculated Visit Level for ED E/M services using presenting problem, diagnostic services performed, and patient complexity/co‑morbidity

Inputs usedPresenting problems (ICD‑10 RFV), diagnostic CPT codes (Lab, X‑ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound), and ICD‑10 principal/secondary diagnoses for complexity

PurposeDetermines the emergency department E/M level to be reimbursed for certain facility UB‑04 claims

Effect on claimsFacilities may have submitted Level 4 or 5 E/M codes adjusted to the Analyzer result or denied for the submitted level

Facility E/M coding principle

Principle summaryFacility E/M codes should be based on hospital facility resources and intensity of resource use, not on physician resources

Coding intentGuidelines should reasonably relate intensity of hospital resources to different levels of effort represented by the CPT code descriptor

Anti‑upcoding guidanceFacility coding should not facilitate upcoding or gaming and should follow CMS coding principles for outpatient visits including ED services