ED Coding and Reimbursement Alert

"Additional workup planned" may not count in this coverage decision.

Every emergency department regularly reports code 99285 (Emergency department visit for the evaluation and management of a patient...), but one payer appears to have made that a little bit more complicated.

Here's why: Earlier this year, United Healthcare (UHC) updated its evaluation and management (E/M) coding policy, clarifying the number of points that can be counted toward diagnoses and management options when calculating the medical decision-making portion of an E/M code in the emergency department.

The policy now says, "A provider receives three points for 'New Problem, No Additional Work-Up Planned,' and four points for 'New Problem, Additional Work-Up Planned.' This one-point difference can affect whether a level four or level five code is supported by the chart documentation. Please note that all encounters with ED patients are considered 'New Problem' encounters for purposes of scoring."

In addition, UHC defines "additional workup planned" using the following terminology: "Any testing/consultation/referral that is being done beyond that encounter to assist the provider in medical decision making." This is a rather vague description, and could leave EDs with more questions than answers.

What Does the Change Mean?

Many EDs are taking UHC's policy adjustment to mean that in the ED, if no additional workup is planned, a level five visit cannot be reported, thus meaning that this new rule could potentially limit the number of 99285s reported in the ED setting. But the reality is that the issue isn't completely black and white, and the issue of "additional workup planned" is controversial, says Stacie Norris, MBA, CPC, CCS-P,  director of coding quality assurance with Zotec Partners in Durham, N.C.

"Some experts even disagree with using that terminology because it doesn't exist in either CPT^® or the Medicare Documentation Guidelines. It is a Marshfield Clinic construct," Norris says. However, she advises, once you get to the point when you're deciding whether to use the additional workup planned (AWP) as part of your coding tool kit, then you have to define it - and that's a controversial issue as well.

"What is AWP exactly?" she asks. "Is it ordering a CT scan in the ED? An MRI? A consult? There are very different opinions. Is it if you admit the patient to the hospital? Most, if not all, agree that admitting the patient to the hospital is AWP. Where the industry disagrees with UHC is that UHC is saying in its policy that a test ordered in the ED does not count as AWP, but that, say, making an appointment for the patient to have the test the next day does count. And yes, sometimes the ED provider/staff does make an appointment for the patient, depending on the urgency of the situation, but most of the time the AWP is done in the ED."

Most ED coding experts feel that the industry norm supports scoring additional workup planned in the emergency department.

Is There Recourse?

With this in mind, it's clear that emergency departments may have an uphill battle in making sense of the somewhat ambiguous changes to United Healthcare's policy. However, like any other payers, UHC is likely to consider appeals when you feel they are warranted.

If UHC reviews your chart documentation and denies a claim with 99285, you can write an appeal letter explaining why you believe your documentation demonstrates additional workup planned. If, however, you do not think AWP should even be used as a term to determine E/M levels, then you can use that argument in your letter, Norris says. You can say you treated extensive diagnoses and management options for the patient, and that this justifies the code.

"Then there is also the issue of whether or not the provider or group participates with UHC," Norris says. "If they do not participate, then UHC should not be downcoding their claims at all due to UHC's internal coding policies."

Resource: To read UHC's policy in its entirety, visit https://www.uhccommunityplan.com/content/dam/communityplan/healthcareprofessionals/reimbursementpolicies/Evaluation_Management_Policy_(R5007).pdf.