CODING Q&A Addressing Problem-based Coding and Other Challenges ■ DAVID STERN, MD, CPC Q . We are a fairly new urgent care center and could use some help on E/M coding. I have read on var- ious urgent care websites that we can bill each visit as a new patient visit (as long as it isn’t a follow-up to an ex- isting problem). Can you please give me some direction on where I can find this information? What you are referring to is “problem-based coding.” Never code in this way unless you have clearly com- municated with the payor about this method. Problem-based coding is one way for urgent care centers to receive appropri- ate compensation for the additional expenses incurred in pro- viding urgent care services. You can access an article on this subject at: http://www.ucaoa.org/info/resources.html (click on “problem-based coding”). A. Q . We are starting an urgent care clinic. Should we bill using place-of-service (POS) -11 (office) or POS- 20 (urgent care facility)? In this situation, CMS defines an office as “[a] location, other than a hospital, skilled nursing facility (SNF), mil- itary treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.” An urgent care facility is defined as “[a] location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate med- ical attention.” A. 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 dstern@practicevelocity.com. w w w. j u c m . c o m Of course, if you are operating a facility that would meet the UCAOA definition of an urgent care center, then POS-20 would be the most accurate code to use. In coding, there is a general rule to use the most accurate code to describe the services rendered. In the case of place-of- service codes, another common rule comes into play. This rule is what I sometimes jokingly refer to as the “make-sure- that-you-give-the-payors-what-they-want” rule. Some payors will refuse to pay on the POS-20 code. Others may have their computers set up to only accept POS-20 from your center. In some cases, payors will accept either code. Some payors may use POS-20 to trigger a rule to allow problem-based cod- ing. Others never allow problem-based coding. For Medicare, each fiscal intermediary is different—some require POS-20 and others want you to use POS-11. You must determine the preference of your fiscal intermediary, or your claims will be de- nied. Some payors cannot tell you which code you should use, but they will deny any claims submitted from your center with POS-11. This has been a source of 100% denials for at least one ur- gent care center in dealing with one particular payor. The payor was unable to tell the urgent care center what the rea- son was for the denials. After six months of having every sin- gle claim denied, the urgent care center tried using POS-20; and, voila, suddenly rejections ceased and their claims were processed and paid. So, you can see some payors may not even be aware of their own software rules for place-of-service codes for your urgent care center. Q . We saw a patient for bronchopneumonia and the physician removed an ear wax impaction on the same visit. We coded a 99213 (level 3 E/M code), 69210 (removal impacted cerumen), and 71020 (two-view chest radiograph). Payment for the E/M code was denied. Why? Code 69210 should have been attached to the diagno- sis for impacted cerumen (380.4) and the chest radi- A. JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | N o v e m b e r 2 0 0 7 39