Q. Payors do not seem to want to pay on the code E0572 (aerosol compressor, adjustable pressure, light duty for intermittent use). What can we do to get payment?

A. This code is not for simple use of the aerosol compressor, but is actually used to code for sale of the actual nebulizer machine. Thus, this code would rarely be appropriate for use in the urgent care setting.

Q. How do we get payors to reimburse for albuterol medications? They do not seem to pay on codes J7603 and J7609.

A. Medicare listings for the albuterol codes have been in a state of constant flux for the past few years. You should not use J7603 and J7609, as these have been removed from the Medicare fee schedule in 2008.

The appropriate codes are:

• J7611: concentrated albuterol (per 1 mg)
• J7612: concentrated levalbuterol (per 0.5 mg)
• J7613: unit dose albuterol (per 1 mg)
• J7614: unit dose levalbuterol (per 0.5 mg)

Use each code once for each milligram that is administered. For example, if you administer 2 mg of concentrated albuterol (usually diluted with saline), then you would code J7611x2.

Q. What is the proper coding for the administration of nebulizer treatment procedures?

A. Typical coding for nebulizer therapy for asthma in an urgent care setting would be:

• 94640: first nebulizer treatment
• 94640: each subsequent nebulizer treatment on each day
• A7003: administration set, with small volume non-filtered pneumatic nebulizer, disposable
• Use J7611, J7612, J7613, J7614 per the answer to the previous question.

Q. A national payor is clamping down on the 99051 code, claiming urgent care centers may not use this code because it is customary for urgent care centers to provide these hours of service and urgent care centers are already paid more than other physician practices (which is not necessarily the case).

A. The payor is mistaken that the code 99051 is only for hours outside of your “customary hours of service,” as the AMA defines this code as being for use during “regularly scheduled office hours.” Thus, this code should never be used for services rendered other than regularly scheduled clinic hours.

In fact, there is a specific code (99050) for services rendered “at times other than regularly scheduled office hours.” Thus, not only is that payor mistaken, but there is another code that is appropriate to the circumstances they describe. You were coding correctly.

As a general rule, payors can do what they want when reimbursing for these codes. As for take-backs, you may want to look at your contract to see if they have the right to do a take-back in this way. It sounds as though they have changed their rules for coding and are now trying to retroactively apply the new rules. You may need to contact a lawyer to see if you have a legal case to prevent the payor from applying new rules to old claims.

Usually, we try to use this type of a move by a payor as an opportunity to get a face-to-face meeting to explain:

• The benefits that the payor receives from afterhours care:
  – Marketing to employers (i.e., we include quality urgent care providers).
  – Making their most profitable members (i.e., the walking well that utilize very few healthcare resources) happy with their coverage.
  – Reduced emergency department visits.
• The additional costs that your urgent care incurs by providing after-hours care:
  – Wages; we must pay more than typical primary care where hours are 9-5, Monday through Friday.
  – Down time occurs when you are open—and paying staff—even when no patients come through the door, which can occur for hours at a time. When primary care practices have no scheduled visits, they can simply close up shop.
  – Staffing to rush: Due to non-scheduled visits, an urgent care center needs to slightly overstaff so that unacceptable delays do not occur during unexpected rushes of patients.

Then we tell the payor that there are many different ways for the payor to reimburse urgent care centers for these added expenses. Payors sometimes use S9088, 99051, problem-based coding (PBC), a fee schedule at about 120% of primary care fee schedule, or some other method.

The key issue is that we need a mutually beneficial way to continue the relationship. They want urgent care centers to serve their clients, and urgent care centers need adequate reimbursement to pay the electric bill.

David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at