Definitions

Additional Work-up Planned 

Any testing/consultation/referral that is being done beyond that Encounter to assist the provider in medical decision making.

Encounter

Interaction between a covered member and a health care provider for which evaluation and management service or other service(s) are rendered and results in a claim submission

Questions and Answers 

1 Q: When a separate written report for diagnostic tests/studies is prepared by the same individual performing the E/M service in an ER/ED place of service, should this be considered as a factor in the E/M code selection?  

A: No. Any specifically identifiable procedure reported separately from the E/M service should not be considered in the selection of E/M service level reported. For example, a patient presents to the ER/ED with chest pain and an EKG is performed. The EKG is normal; the attending provider determines that the patient has angina and provides a prescription. This would NOT be considered Additional Work-Up Planned because the test was performed and a diagnosis was made during the ER/ED Encounter. If another provider other than the attending provider (such as a cardiologist or radiologist) bills the CPT code for the interpretation, then 2 points are scored because the attending provider is not billing for the interpretation separately.

2 Q: Will UnitedHealthcare require medical records for all reported E/M services? 

A: No. UnitedHealthcare requests medical records when the data indicates a physician or other health care professional has a billing pattern that deviates significantly from their peers. 

3 Q: What if the Encounter doesn’t require Additional Work-up Planned but does require high complexity medical decision making (MDM)? 

A: The provider may submit medical records for review. Consideration will be given to the medical record provided. The Additional Work-up is a component of the number of diagnoses and management options. There are two other elements – amount/complexity of data and the table of risk which contribute to the medical decision making element. CPT also notes that when counseling and/or coordination of care dominates more than 50% of the encounter with the patient and/or family, then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. 

Additional Work-up Planned

The Additional Work-Up Planned is a key element for a highly complex E/M service and constitutes any testing/consultation/referral that is being done beyond that Encounter to assist the provider in medical decision making. An example of Additional Work-Up Planned is when the provider of service contacts the patient’s physician or other specialist with recommendations for additional follow-up care and the discussion is documented in the medical records. A simple instruction to the patient to contact their primary physician does not constitute Additional Work-up Planned.

The examples below are based on a record review assessment and further illustrate the medical decision making component scoring above.

Office E/M documentation: 

(1) Established Problem- Worsening: An established patient sees his/her gastroenterologist due to worsening of his/her Crohn’s disease. The physician provides an E/M service and adjusts the patient’s medication. Two (2) points would be assigned for Established Problem- Worsening score. 

(2) New Problem-Additional Work-up planned: The patient presented to his/her new family practitioner with symptoms requiring additional tests and/or a referral to a specialist. In addition the family practitioner contacts the specialist directly to discuss the patient’s case. Four (4) points would be assigned for New Problem-Additional Work-up Planned score.  

Overview

This policy is intended to address Evaluation and Management (E/M) services reported using Current Procedural Terminology (CPT®) codes 99201-99350. Each code contains three (3) "key" components: history, examination and medical decision making, which are used as a basis for selecting a level of E/M code that best describes the service rendered to the patient.

The E/M coding section of the CPT® book is divided into broad categories with further sub-categories which describe various E/M service classifications.

The classification of the E/M service is important because the nature of the work varies by type of service, place of service, the patient’s medical status, and other code criteria, along with the amount of provider work and documentation required. The key components appear in the descriptors for most basic E/M codes and many code categories describe increasing levels of complexity.

CPT provides guidelines for the appropriate selection of E/M codes and the required documentation. In addition, CMS published E/M documentation guidelines in 1995 and 1997 for each of the key components of E/M services. 

The documentation of the three components (history, examination and medical decision making) depends on clinical judgment of the provider and the nature of the presenting problem(s). Each of these three components has different levels of complexity. 

This policy describes when E/M records may be requested and the UnitedHealthcare methodology used for medical record review under this policy.

Reimbursement Guidelines

This reimbursement policy explains when medical records may be requested to ensure that the appropriate level of CPT E/M code is reimbursed based on the health care services provided. The code(s) reported by physicians or other health care professionals should best represent the services provided based on the AMA and CMS documentation guidelines.

UnitedHealthcare uses an Optum proprietary scoring tool based on the instructions in the 1995 and 1997 CMD documentation guidelines. Medical records are requested when the data shows a physician or other health care professional has a billing pattern that deviates significantly from their peers. 

The medical record review process takes into consideration CMS documentation guidelines. Based on the record review points are assigned in accordance with the documented medical record. 

Additional Work-up Planned is an element of review which includes a number of diagnoses and management options. The Additional Work-up Planned element contributes to indicating the complexity of a patient based on the clinician’s utilization of diagnostic tests. 

  

REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies may use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. 

This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy.

This information is intended to serve only as a general reference resource regarding UnitedHealthcare’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, the enrollee’s benefit coverage documents and/or other reimbursement, medical or drug policies.