Rejected Codes by Payer FAQ

Insurance companies inappropriately started denying emergency department payments for nonurgent conditions as far back as the 1980s-1990s. This was addressed for Medicare/Medicaid (traditional) programs in 1997 in the Balanced Budget Act, which included the Prudent Layperson Standard requiring coverage of emergency services based on the patient’s reasonable belief of an urgent condition rather than focusing on the ultimate diagnosis or ICD-10 codes. This was later extended to private health plans, individual market plans, and ERISA plans in 2010 with the Patient Protection and Affordable Care Act (ACA). 

ICD-10 diagnosis codes, maintained by the World Health Organization, were developed to classify diseases, injuries, and causes of death and provide critical data for tracking health trends, mortality, and morbidity. They were not intended to be utilized for reimbursement purposes.

Many payers have released a list of ICD-10 codes that they consider “nonurgent”. A recent example includes an ICD-10 list referred to as a LANE (Low Acuity Non Emergent) list. A few payer lists are attached for reference.  If you have questions regarding a specific payer diagnosis list, review the Provider Manual and Clinical Policies for that payer.  Payers may describe criteria or coding methodology rather than formally publishing their diagnosis lists.  

The use of diagnosis-based algorithms or “nonurgent” diagnosis lists to deny or downcode emergency department CPT claims is inconsistent with established reimbursement principles and the prudent layperson standard.  ICD-10-CM codes are intended for disease classification and reporting purposes, not as the primary driver of CPT coding.  Reliance on diagnosis only disregards coding standards and the complexity of emergency presentations and clinical decision making. 

• https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/ad_a005_administrativepolicy_emergency_services.pdf
• https://www.horizonblue.com/providers/policies-procedures/policies/reimbursement-policies-guidelines/evaluation-and-management-services-emergency-department
• https://test.njmmis.com/downloadDocuments/ICD10_Non_Emergent_Listing_2024.pdf
• https://providers.highmark.com/communications-hub/news-and-updates/low-acuity-non-emergent-professional-claim-review.html
• https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/rp-drafts/rp-037-de-pa-wv.pdf
• https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/rp-drafts/rp-037-ny.pdf

These lists may  contain well over 3,000 ICD-10 codes. The diagnoses included often represent common complaints, that if not addressed in an emergent manner, could lead to dire consequences. Under the prudent layperson standard, an emergency is determined based on whether a reasonable person with average knowledge of health and medicine would believe that immediate medical attention is necessary to prevent serious jeopardy to health, impairment of bodily functions, or dysfunction of any bodily organ or part.  

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 not expected to be healthcare professionals, nor are they expected to be able to diagnose themselves, using artificial/autonomous intelligence resources, or any publicly available information. 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 would be paid for by their insurance. Insurance companies have 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, one payer who insures more than 12 million patients in 20+ states through government-sponsored healthcare programs, announced in 2017 that “nonurgent” diagnoses coded as 99285 would be reduced to a 99283 level. There was no available list of their “nonurgent” diagnoses.

Other payers use software to match patient age and diagnosis to determine payment.

Contact Jessica Adams, ACEP Reimbursement Director, with details of your case. She may be reached at (469) 499-0222 or jadams@acep.org.