Urgent Care Center Coding and Reimbursement

Operators of urgent care centers are familiar with the notion that they can’t code using emergency room E/M codes (99281-99285) as they do not meet the CPT definition of emergency room. An emergency room must be hospital- based and open around the clock. These requirements are not “either/or;” they are “and,” to indicate both conditions must be met. This means urgent care centers should use the new and established outpatient codes 99201-99215 for reporting encounters.

As of Jan. 1, 2003, urgent care centers have been designated as place of service (POS) 20 per the Centers for Medicare & Medicaid Services (CMS) under the Health Insurance Portability and Accountability Act (HIPAA). They are also classified as non-facility (NF) under CMS. This is in contrast to Emergency Room-Hospital, POS 23, classified as a facility (F) under the same system. The excerpts below, from Transmittal 1049, dated Sept. 1, 2006 (Change Request 4316), provide this information:

This information tells us that the urgent care center should not be subject to site of service fee reduction. However, this is not the case if the center is owned and operated by a hospital. It is then considered another outpatient arm of the institution. Medicare has two fee schedules: one for physician services performed in a “non-facility,” and one for services performed in a “facility.” Payors are going to receive billing from both the facility and the provider in the case of facility services. A good example of this is if radiologic services are provided. In POS 20, the full fee is submitted and paid. In POS 21-23 (inpatient, outpatient and ED sites of service), a payment split between technical (70 percent) and professional (30 percent) services. The physician reading the radiograph who is not an employee of the hospital would code the service with modifier 26 for professional component only, and the facility would add modifier TC for the technical component. The professional (physician) reimbursement would be 30 percent of the total, and the facility reimbursement would be 70 percent of the total.

Many pediatric practices offer after-hours services. Is this the same as an urgent care facility? Can you code with an after hours code from the 99000s? If  you take down your daytime shingle and put up a new one, do you have the two businesses set up under separate tax IDs? If you operate under posted office hours into the wee hours of the evening are your services really “after hours?”

The aforementioned issues speak to problems plaguing physician-owned “after hours” and/or urgent care centers. This type of practice provides a middle tier of service to patients who either get sick suddenly or just can’t get themselves or their children in until after working hours. These patients are generally not critically ill, nor should they be. Critical, life-threatening problems should go to the ER where there are adequate resources for life support. If these same patients reported to the ER, the cost to insurers is almost double until the facility fees are satisfied. So why wouldn’t they want to pay a $20 to $40 after-hour fee to support the services offered at less than conventional hours? It might be that they will when you go to renew your contract. This is the best place to address the issue, whether it is added into negotiated rates or reimbursed at a flat fee with 99051.

Successful urgent care center coding and reimbursement depends on correct use of modifiers, linkage of appropriate diagnoses to procedures, thorough documentation and reimbursement for medications and DME.

According to CMS, modifier 25 is one of the most misused modifiers in procedural coding. Modifier 25 depicts a separate, significant and identifiable E/M service above and beyond other service. Although it is designed to be appended to an E/M service, many providers append it to a surgical code in error.

While CPT no longer states a separate diagnosis is required to use this modifier, many third party adjudication systems are hard-wired to look for one for payment. If the patient is seen for a fall on the ice with a bump to the head and a laceration to the forearm, the provider may have evaluated the patient for head injury prior to suturing. If the documentation reflects this it would be appropriate to place modifier25 on the E/M service and list it in addition to the wound repair code. There should be two diagnoses reported (one for the laceration and one for the bump on the head), and they need to be linked to the appropriate service. For example, 12034 for the repair is linked to 881.00 for open wound of forearm and evaluation and management code 99203-25 is linked to 850.0 for the concussion. Remember, documentation must reflect both services were actually performed, preferably with a separate note for each:

Stocking medications is a financial burden and many offices and after-hours operations have can have a difficult time getting reimbursed for drugs. Make certain your staff is reporting the correct HCPCS Level II J codes and the correct number of units to reflect the dose administered.

Commonly, a chart note reads, “Give 2 cc of medication X.” This may be the only indicator on the entire chart for the encounter in question that medication was even considered. The reality is much more complex. First, the person administering the medication must make a note of time, date, route and site if applicable of administration.

Then it is imperative that the units per cc be documented. J codes are reported in unit. If a patient gets 3 mg of decadron and the J code for that drug is listed as decadron in 1 mg units, then three must be placed in the units field to get full reimbursement for what was given. It is recommended invoices be submitted in instances where payment does not meet expenses. There are now several options for drug reimbursement through CMS that should also be thoroughly explored.

If you are providing equipment such as crutches, be certain you have a DME provider number and are submitting to the correct DME carrier for your region. Check the Stark requirements to ensure you are in compliance. The appropriate HCPCS code would need to be listed on the claim. Lastly, make certain the appropriate E code is on the claim for injuries and that the claim is going to the appropriate payer. Sending a workers’ comp or automobile injury to the patient’s medical insurer will only delay payment.

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