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Rejected Codes by Payer FAQ

  • One of our patient’s emergency department bill was not paid by their insurance company. The company said the diagnosis was “nonurgent.” When did this start?

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    Answer

    Insurance companies wrongly started denying emergency department payments in late 2017 based on certain diagnoses or ICD-10 codes. The controversial policy began in Georgia, Missouri, and Kentucky. Other state insurers may follow with similar plans. Ohio, Indiana, and New Hampshire were scheduled to implement related policies in January, 2018.

    Answer

    Insurance companies wrongly started denying emergency department payments in late 2017 based on certain diagnoses or ICD-10 codes. The controversial policy began in Georgia, Missouri, and Kentucky. Other state insurers may follow with similar plans. Ohio, Indiana, and New Hampshire were scheduled to implement related policies in January, 2018.

  • Is there a publicly available list of these alleged “nonurgent” diagnoses? Where can I get a copy?

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    Answer

    Anthem Blue/Cross BlueShield released a list of ICD-10 codes that they considered “nonurgent.”

    Answer

    Anthem Blue/Cross BlueShield released a list of ICD-10 codes that they considered “nonurgent.”

  • What are some examples of the diagnoses on the Blue Cross/Blue Shield list?

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    Answer

    The list includes well over 1,000 ICD-10 codes. The diagnoses that are on the list include common complaints, that if not addressed in an emergent manner, could lead to dire consequences.  Though too  long and broad to easily organize, a few examples follow: the diagnosis of pleuritic chest pain which could be due to a pulmonary embolism; the diagnosis of conjunctivitis that might actually be a corneal ulcer, a gonococcal infection, or even acute angle closure glaucoma, all of which may lead to the patient losing their vision; the diagnosis of vertigo that could be the presenting symptom of an ischemic stroke;  and the diagnosis of gonococcal infection of the lower GU tract that could lead to pelvic inflammatory disease, putting the patient’s future reproductive ability at risk.  These are just a few examples of presenting symptoms and ICD-10 codes that often include serious disease and might lead to very unfortunate outcomes if the patient does not seek immediate medical attention.

    Answer

    The list includes well over 1,000 ICD-10 codes. The diagnoses that are on the list include common complaints, that if not addressed in an emergent manner, could lead to dire consequences.  Though too  long and broad to easily organize, a few examples follow: the diagnosis of pleuritic chest pain which could be due to a pulmonary embolism; the diagnosis of conjunctivitis that might actually be a corneal ulcer, a gonococcal infection, or even acute angle closure glaucoma, all of which may lead to the patient losing their vision; the diagnosis of vertigo that could be the presenting symptom of an ischemic stroke;  and the diagnosis of gonococcal infection of the lower GU tract that could lead to pelvic inflammatory disease, putting the patient’s future reproductive ability at risk.  These are just a few examples of presenting symptoms and ICD-10 codes that often include serious disease and might lead to very unfortunate outcomes if the patient does not seek immediate medical attention.

  • Isn’t it dangerous to tell patients that they may have no coverage, and payment will be rejected, if they present to the emergency department with a “nonurgent” complaint?

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    Answer

    Yes, it is. Time matters in emergent situations and patients need to know that they will be receiving the best medical care possible – they should not be worrying about whether their insurer will cover their visit. When patients are incentivized to avoid needed care, serious problems may result. A CDC study from 2014 found that less than 5% of ED visits were labeled as nonurgent.  This signifies that patients are seeking care for their complaints that require emergent care in an appropriate manner.

    1 Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables. Available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2014_ed_web_tables.pdf

    Answer

    Yes, it is. Time matters in emergent situations and patients need to know that they will be receiving the best medical care possible – they should not be worrying about whether their insurer will cover their visit. When patients are incentivized to avoid needed care, serious problems may result. A CDC study from 2014 found that less than 5% of ED visits were labeled as nonurgent.  This signifies that patients are seeking care for their complaints that require emergent care in an appropriate manner.

    1 Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables. Available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2014_ed_web_tables.pdf

  • Are patients expected to properly diagnose themselves?

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    Answer

    Patients are definitely not expected to be healthcare professionals, nor are they expected to be able to diagnose themselves. The ‘prudent layperson’ standard requires that insurance coverage be based on a patient’s symptoms, not their final diagnosis. If a patient believes they have the symptoms of a medical emergency, they should seek care immediately and have assurances that their visit with be paid for by their insurance.   Anthem has been quoted to say that they are attempting to “steer their patients to proper care,” when in reality they could be leading their patients into the path of detrimental outcomes or even worse, death.

    Answer

    Patients are definitely not expected to be healthcare professionals, nor are they expected to be able to diagnose themselves. The ‘prudent layperson’ standard requires that insurance coverage be based on a patient’s symptoms, not their final diagnosis. If a patient believes they have the symptoms of a medical emergency, they should seek care immediately and have assurances that their visit with be paid for by their insurance.   Anthem has been quoted to say that they are attempting to “steer their patients to proper care,” when in reality they could be leading their patients into the path of detrimental outcomes or even worse, death.

  • Is there any recognition of the ‘prudent layperson’ standard in current law?

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    Answer

    Yes - the most recent is the Affordable Care Act. When written and passed by our legislative branch, the 111th Congress included the ‘prudent layperson’ standard and even defined it:

    “EMERGENCY MEDICAL  CONDITION – The term ‘emergency medical condition’ means a medical  condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social  Security Act.”

    [downloaded at: https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf - page 771]

    Answer

    Yes - the most recent is the Affordable Care Act. When written and passed by our legislative branch, the 111th Congress included the ‘prudent layperson’ standard and even defined it:

    “EMERGENCY MEDICAL  CONDITION – The term ‘emergency medical condition’ means a medical  condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social  Security Act.”

    [downloaded at: https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf - page 771]

  • Are some charges being reduced by insurers based on the diagnosis? 

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    Answer

    Yes, Centene Corporation insures more than 12 million patients in more than 20 states through government-sponsored healthcare programs. They announced in 2017 that “nonurgent” diagnoses coded as 99285 would be reduced to a 99283 level. There is no available list of their “nonurgent” diagnoses.

    United Healthcare intended to use software to match patient age and diagnosis to determine payment.   They have since decided to hold until after the COVID 19 emergency.

    Answer

    Yes, Centene Corporation insures more than 12 million patients in more than 20 states through government-sponsored healthcare programs. They announced in 2017 that “nonurgent” diagnoses coded as 99285 would be reduced to a 99283 level. There is no available list of their “nonurgent” diagnoses.

    United Healthcare intended to use software to match patient age and diagnosis to determine payment.   They have since decided to hold until after the COVID 19 emergency.

  • Who should I contact if my patients have their payment rejected or if my level of service is reduced by their insurer?

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    Answer

    Contact Mr. David McKenzie at ACEP with the details of your case. He may be reached at:

     dmckenzie@acep.org or (469) 499-0133

    Answer

    Contact Mr. David McKenzie at ACEP with the details of your case. He may be reached at:

     dmckenzie@acep.org or (469) 499-0133

Updated March 2021

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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