Six Common Mistakes to Avoid in Urgent Care Billing
by Sheri Poe Bernard, CPC, CPC-H, CPC-P
11/01/2007
The number of new urgent care facilities cropping up across the nation these days speaks to the potential for this clinical trend. But success depends on more than just a great business plan, prime location and experienced clinical staff. You’ve got to have the right coding and billing policies in place to ensure you keep the revenue coming and to protect the practice from the risks of noncompliance. What follows are six common billing and coding mistakes seen in urgent care facilities.
1. Misrepresenting PA and NP Services
Many urgent care facilities employ physician assistants (PAs) or nurse practitioners (NPs) as mid-level providers of services “incident to” a physician’s care. These lower-cost clinicians often replace physicians as care providers, and their services can be reimbursed by Medicare in either of two ways: “incident to,” in which the NP or PA is seen as an extension of the physician, and the service is reimbursed at 100 percent of the physician fee schedule; or independent care, in which the NP or PA is seen as an independent clinician and the service is reimbursed at 85 percent of the physician fee schedule.
Medicare payment rules are very precise for “incident to” services billed to Medicare. Key among them:
“Incident to” services require that the physician have an established relationship with the patient. Therefore, services to a patient who is new to the urgent care facility would not qualify.
“Incident to” services require that the physician have a plan of care for the patient. Therefore, the physician would need to have seen the patient for the current presenting problem at least once.
The physician must be on the premises during the “incident to” encounter.
Violators may be required by Medicare to reimburse overpayments and pay significant fines.
These rules make it very difficult for a mid-level provider in an urgent care setting to bill under the physician, as most visits are either a new patient or a new problem. If PAs and NPs can bill under their own identification numbers, then the waiting room is their oyster.
Other payors have varying rules for “incident to” billing, and business managers should make queries and share payor-specific requirements with billers, coders, and providers. The best strategy for approaching this is to query the top five payors in your area and get their midlevel payment policies in writing. Then you can gauge your ability to best utilize these providers.
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