New Policy from UnitedHealthcare

September 22nd, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA

Categories: Evaluation & Management (E/M) Modifiers Denials & Denial Management

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In the June 2017 UHC Network Bulletin, there was an article that addressed UHC's decision to no longer pay for consultation services. We have shared this information in previous audit tips and emails, but there is an additional point within that bulletin that was located on that same page, buried in a color bordering of the page.

The following is an excerpt:

New policy - Advanced Practice Health Care Professional Evaluation and Management Procedures Policy Effective for claims with dates of service on or after September 1, 2017, UnitedHealthcare will require physicians reporting evaluation and management (E/M) services on behalf of their employed Advanced Practice Health Care Professionals to report the services with a modifier to denote the services were provided in collaboration with a physician. UnitedHealthcare will accept the modifier SA on claims for these services when provided by nurse practitioners, physician assistants and clinical nurse specialists. In addition, the rendering care provider's National Provider Identifier (NPI) must also be documented in field 24J on the CMS-1500 claim form or its electronic equivalent. Use of the modifier SA and documentation of the rendering care provider will assist UnitedHealthcare in maintaining accurate data with regard to the types of practitioners providing services to our members.

I have written a more in-depth article on this update that will be published by RACmonitor this month, but we are already 22 days into this month, and those not knowing about this change may already have a significant volume of claims affected. This will significantly affect the ability of UnitedHealthcare to further scrutinize claims that are being performed incident-to. Previously, these claims were "vulnerable" through post payment review, and the ability of the carrier to flag them from a utilization standpoint exists (through monitoring RVU and time), but was not the most reliable.

Be sure that you are following and meeting incident- to guidance, and be prepared for audits on these services at any time.

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