University of Colorado Health $23M settlement a red flag for over-reliance on automated coding

By Jason Jobes

FALSE CLAIMS ALERT: University of Colorado Health has agreed to pay the United States $23M for false claims tied to E/M levels billed for emergency department services. At its core technology makes good—or bad—processes move faster.

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It is vital to state that this suit does not represent an admission of guilt. The settlement states this “is neither an admission of liability by UCHealth nor a concession by the United States that its claims are not well founded. “

A whistleblower suit against UCHealth was filed alleging that UCHealth used technology inappropriately in assigning E/M levels for emergency department visits.

The suit says that from 11/1/2017 to 3/31/2021 certain UCHealth hospitals allegedly automatically coded certain claims for ER visits using CPT 99285. This automation was performed whenever providers at UCHealth Hospitals checked a set of the patient’s vital signs more times than total hours that the patient was present in the ED, excepting patients who were in the ED for fewer than 60 minutes, despite the severity of the patient’s medical condition or the hospital resources necessary to manage the patient’s health and treatment. 

UCHealth sometimes referred to this coding rule as the “frequent monitoring of vital signs.”

What jumps out to me is the following paragraph from the filing:

“The United States alleges that UCHealth knew that this automatic coding rule associated with “frequent monitoring of vital signs” did not satisfy the requirements of the CPT code description for CPT 99285 and did not reasonably reflect the facility resources utilized by the UCHealth Hospitals. UCHealth received numerous complaints from its coding employees warning about the use of CPT 99285 based on the automatic coding rule associated with “frequent monitoring of vital signs.” UCHealth also received and responded to individual patient complaints, but did not adjust its automatic coding rule systemically. Further, UCHealth was consistently identified, in reports received from the Centers for Medicare & Medicaid Services, as a “High Outlier” for its CPT 99285 E/M billing during the Covered Period.”

Technology is a support mechanism and operates as programmed. In this way a potential imperfection in the algorithm had rippling effects. Further, when identified there was limited action taken to review and rectify the concern.

Here are 3 things to consider:

1) Evaluate your risk—level 5 visits are a known risk area. Perform regular reviews of high-risk areas.
2) If risk is high, understand what processes and technology may contribute to risk.
3) Ensure there are adequate feedback loops to address team member and patient concerns, especially in high risk areas.

The whistleblower in this case received $3.91M of the proceeds from the settlement.

If you are in need of a code audit (CPT, HCPCS, E/M, or ICD-10-CM/PCS) or a software compliance check, we’re here to partner with you. Contact me at jason@norwood.com. 

Reference

Department of Justice, UCHealth Agrees to Pay $23M to Resolve Allegations of Fraudulent Billing for Emergency Department Visits: https://www.justice.gov/opa/pr/uchealth-agrees-pay-23m-resolve-allegations-fraudulent-billing-emergency-department-visits