Medicare Compliance & Reimbursement - 2020 Issue 11
E/M Coding: Understand What “Additional Workup Planned” Means to This Payer
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Article Overview
This article reviews a UnitedHealthcare emergency department E/M policy that introduced payer-specific language affecting medical decision making review and claim evaluation. It discusses why the issue has drawn concern among emergency department coders, how the policy differs from broader Medicare and CPT framing, and why providers may need to review documentation or pursue appeals when claims are denied. The content is relevant to emergency department coding professionals, reimbursement staff, and anyone tracking payer-specific E/M guidance.
Why This Topic Matters
Payer-specific E/M interpretations can affect documentation review, code selection, and denial management in the emergency department. Understanding this policy helps coding and billing teams recognize when a claim may be subject to a unique UHC review standard rather than general national guidance.
Article Sections
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Background
Introduces the payer policy issue and explains why it became a point of confusion for emergency department coding and medical decision making review.
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Discover How to Qualify for 4 Points
Summarizes the payer’s explanation of its point-based approach and the terminology it uses in relation to emergency department encounters.
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Medicare, CPT® Guidelines Don’t Use These Terms
Addresses the relationship between the payer’s policy language and broader Medicare and CPT-oriented guidance, including the concerns raised by coders and the payer’s response.
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Appeal When Necessary
Covers the option of appealing denied claims and the general approach discussed for contesting a payer decision.
What You Will Learn
- How a payer-specific emergency department E/M policy is framed
- Why the policy has caused confusion among emergency department coders
- How the article contrasts payer language with Medicare and CPT guidance
- What the article says about handling denials through appeal processes
Who Should Read This
- Emergency department coders
- Hospital reimbursement staff
- Revenue cycle professionals
- Compliance staff
- Physician billing teams
Codes Discussed
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