UHC downgrading ED facility coding level 4 and 5 99284/99285

As some of you may have experienced, UHC has implemented their policy on ED visit coding. You can read the policy on page 12 at this link: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/December-Interactive-Network-Bulletin-2017.pdf

It is interesting because there are no official guidelines for code selection; each facility should have their own code selection guidelines so UHC is "forcing" their own proprietary coding guidelines on hospitals.

Furthermore, PEPPER has started to report 99285 usage.

On a recent NAHRI call, it was suggested that every facility  review their coding guidelines for facility ER visits, first to be sure they exist and then to be sure they are sensible. Then check your payer contract to see if it allows or forbids UHC from downcoding automatically. Also look at your PEPPER data to see how you compare for Medicare patients. 

Have any hospitals had any ED visit coding downgraded by UHC? Did you think it was appropriate? Will you appeal? 


  • We have had 2 accounts downgraded and will appeal.  On our EOB there was not a RA code of any kind to indicate the CPT code had been changed.  We billed with 99214 and the EOB said 99213.  Since our payments are posted electronically, we would not have noticed it.  We have created a report that is run weekly to identify any account with UHC as the payor and 99214 or 99215.  That is how we found these two accounts.  Please note, this policy also applies to Medicare Advantage plans.
  • Wow! They are even downgrading office visits! No notification? No chart review to see the actual progress note? 
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