Rejected Codes by Payer FAQ

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.

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

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.

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 2018 found that 3.1% of ED visits were labeled as nonurgent. This indicates patients are seeking evaluation for their complaints that require emergent care in an appropriate manner.

Cairns C, Kang K, Santo L. National Hospital Ambulatory Medical Care Survey: 2018 emergency department summary tables. Available from:

https://www.cdc.gov/nchs/data/nhamcs/web_tables/2018-ed-web-tables-508.pdf

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.

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]

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.

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

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