Part B Insider - 2020 Issue 11
E/M Coding: Understand What “Additional Workup Planned” Means to This Payer
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Article Overview
This article discusses a UnitedHealthcare emergency department evaluation and management policy and why its interpretation of medical decision making has drawn attention from coders and emergency medicine practices. It explains the general issue, references Medicare and CPT guidance for comparison, and describes the kind of payer communication and appeal considerations that may arise when claims are challenged. The piece is most relevant to emergency department coders, billers, and reimbursement staff who handle payer-specific E/M review policies.
Why This Topic Matters
Payer-specific interpretations can change how ED E/M documentation is reviewed and may affect claim outcomes, denials, and appeals. Understanding the scope of the policy helps coding teams recognize when a payer’s approach differs from broader guidance.
What You Will Learn
- Why a payer-specific E/M policy can affect emergency department coding review
- How the article frames the relationship between medical decision making and high-level ED visits
- Why coders compare payer guidance with Medicare and CPT guidance
- What kinds of documentation disputes can lead to appeals
- How emergency department coding staff may respond when a payer denies a claim
Who Should Read This
- Emergency department coders
- Medical billers
- Reimbursement specialists
- Revenue cycle staff
- Emergency medicine practice managers
Codes Discussed
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