Urgent care facilities sometimes make the mistake of reporting evaluation and management services with CPT codes 99281-99285, since emergency room services resemble the unscheduled, episodic services of an emergency room more than the services of a physician office. However, CPT guidelines specifically state that 99281- 99285 are reserved for facilities that are hospital-based and open 24 hours a day. Most urgent care facilities do not qualify under this description.
Using 99281-99285 creates a potential for several problems. Foremost, these codes are reimbursed at a higher level. Their use by an urgent care facility could be seen as fraud or abuse in a retrospective payment audit performed by a payor, and reimbursements for overpayments, and sometimes punitive fines, could be levied. If your facility has been making this mistake and getting paid for it on a significant number of claims, you may want to contact your lawyers to determine what risks exist and to consider a self-disclosure to avoid penalties.
When the correct place of service code is reported (456 for urgent care) with emergency room CPT codes, the payor may note the conflicting information and default to the urgent care site, reimbursing with standard, lower-paying office visit codes, 99201-99215. These office visit codes are tiered according to the level of service and whether the patient is established or new. New patients require more time and are paid at a higher rate than established patients. Because no distinction is made between new and established patients in emergency room coding, the payor will have no information on the status of the claim, and will default the claim to pay the lower amount — for an established patient. Performing your own post-payment reviews of coding and reimbursement will identify if this is a problem at your facility.
Also remember, if you provide extended hours as an urgent care center and take patients without an appointment, then it would be inappropriate to add codes from the after-hours services (99050-99060) series of CPT codes.
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