UnitedHealthcare is delaying the implementation of a new policy that will affect professional emergency department claims submitted with the level 5 evaluation/management code 99285.
UnitedHealthcare, the insurance arm of UnitedHealth Group, said it is delaying the policy in part due to the COVID-19 pandemic.
The new policy, which aligns with CMS and American Medical Association guidelines, aimed to manage the rising cost of ED care. Rising costs are in part being driven by an increase in ED claims that are coded as a level 5, the most severe, according to UnitedHealthcare. The frequency of level 5 ED claims has grown more than 70 percent from 2009-18.
For the policy, UnitedHealthcare had planned on using the Optum Evaluation and Management Professional tool. The tool aimed to reduce administrative burden by reviewing claims to determine appropriate E/M coding levels based on patient age and conditions.
Some providers raised concerns that the tool would lead to automatic downgrades and lower reimbursement. If the policy is implemented in the future, physicians will be able to file an appeal of any decision to deny a level 5 ED claim. The appeal process includes sending medical records for manual review. In addition, some level 5 ED claims are excluded from the policy, including claims resulting from admissions, and care provided to patients with opioid dependence, a drug overdose, schizophrenia and sexual abuse.
UnitedHealthcare said a vast majority of physicians are coding accurately and the policy affects a limited subset of physicians who haven't changed coding practices despite one-on-one consultations.
UnitedHealthcare said it is evaluating the timing of future implementation of the policy.