UnitedHealthcare Medicare Advantage – Outpatient Inappropriate Primary Diagnosis Policy, Facility – Update

Effective Nov. 1, Summary of Changes:

• UnitedHealthcare Medicare Advantage is creating a new reimbursement policy for “Outpatient Inappropriate Primary Diagnosis” for Facility Claims.
• The reimbursement policy will be in accordance with ICD-10 CM and IOCE guidelines and will utilize the data specifications from the CMS Integrated Outpatient Coding Editor (IOCE) to apply diagnosis coding guidelines that identify codes that should never be billed as Primary Diagnosis codes.
• UnitedHealthcare Medicare Advantage will deny claims when a code that is considered an inappropriate diagnosis code based on IOCE coding guidelines is submitted as a primary diagnosis in box 67 on a UB-04 claim form or its electronical equivalent.