University of Colorado Health, known as UCHealth and headquartered in Aurora, Colorado, has agreed to pay $23 million to resolve allegations that it violated the False Claims Act in seeking and receiving payment from federal healthcare programs for visits to its emergency departments, by falsely coding certain Evaluation & Management (E&M) claims submitted to the Medicare and TRICARE programs. E&M claims relate to medical visits that involve evaluating and managing a patient’s health and medical conditions, including qualifying visits to a hospital’s emergency department. In submitting an E&M claim to Medicare or TRICARE, a hospital may use one of five Current Procedural Terminology (CPT) codes (CPT 99281 through CPT 99285), depending on the hospital resources associated with the visit. An E&M facility claim coded with CPT 99285 represents the highest hospital resource usage.
The United States alleged that, from November 1, 2017, through March 31, 2021, UCHealth hospitals automatically coded certain claims for emergency room visits using CPT 99285. UCHealth used this code whenever its healthcare providers had checked a patient’s set of vital signs more times than the total number of hours that the patient was present in the emergency department, excepting patients who were in the emergency department for fewer than 60 minutes, despite the severity of the patient’s medical condition or the hospital resources used to manage the patient’s health and treatment. The United States alleged that UCHealth knew that its automatic coding rule associated with monitoring of vital signs did not satisfy the requirements for billing to Medicare and TRICARE because it did not reasonably reflect the facility resources used by the UCHealth hospitals.
