CODING Q&A Coding for Services Attempted But Not Completed, and Other Reader Queries ■ DAVID STERN, MD, CPC Q . I can’t find any documentation that tells us specifi- cally how we should code when a provider tries to re- move a foreign body, but is not successful and decides that the patient should go to the ER. Do we just code for an of- fice visit or do we also code for the removal of the foreign body since the provider did try, albeit unsuccessfully, and de- cided the patient needed to be seen at the hospital? – Question submitted by both Nancy Wilkes, UCI Medical Affili- ates, Columbia, SC and Alexis Adams, Louisiana Urgent Care, New Orleans, LA A. You may code both: Ⅲ the E/M (if one was documented and performed) with modifier -25 Ⅲ and the procedure code (with a separate and identifiable procedure note) with modifier -53 (discontinued proce- dure). A payor may discount the procedure because of the modi- fier, but you should bill out at full rate. Medicare does not re- duce payment for CPT codes with modifier -53 appended. Do not use modifier -53 for procedures that were planned but never actually performed. Neither modifier -53 nor modifier -52 (reduced services) should ever be reported with an E/M service. Rather, you should report the actual level of service performed. In the case of a patient visit for an emergency condition (un- der 1997 CMS E/M coding guidelines), if the physician is unable to take a full history because of the emergency nature of a visit (example: full review of systems was not performed because of emergency visit), you may indicate this reason for an incomplete history on the chart and take credit for a comprehensive history. David Stern is a partner in Physicians Immediate Care and chief executive officer of Practice Velocity. Dr. Stern and Frank H. Leone, MBA, MPH, are scheduled to speak at a pair of half- day seminars, Urgent Care: 40 Ways to Increase Profitability, in Tampa and Boca Raton, FL July 25 and 26. For more in- formation about the seminars, call Megan Montana at (800) 666-7926, extension 13. Dr. Stern may be contacted at dstern@practicevelocity.com. w w w. j u c m . c o m Note: This only applies to the history part of the E/M docu- mentation. On the physical exam, credit is given only for the actual exam elements and systems that were examined and documented on the chart. No credit should be given for any exam elements that were omitted because of the emergent na- ture of the visit. ■ Q . Is it better to use add-on S9088 or the global code S9083 for urgent care at a primary care facility with extended hours for walk-in patients? – Question submitted by Susan Nation, Camp Creek Urgent and Family Care Center, Atlanta, GA First: These codes are only for true urgent care centers. They should not be used by primary care offices that operate extended hours where they take walk-in patients. Abuse of these codes by practices that do not operate true ur- gent care centers (defined as those that provide significant ex- tended hours, advertise themselves as providing services to the public on a walk-in basis, have x-ray on site and allow walk- in visits during all open hours) creates problems for everyone in the industry. Second: You will need to use the proper codes, based on your contracts with third-party payors: Ⅲ Use S9083 if you have flat-rate per visit contracts. Ⅲ Use S9088 if a specific payor agrees to reimburse this code. Ⅲ Never use either code for Medicare. ■ A. Q . We are a urology practice that offers daily “on call” services in which patients can be seen on an urgent basis. What are the requirements of being able to bill as an “urgent care” center and/or state licensing requirements? – Question submitted by Patricia Williams, Urological Associ- ates, Davenport, IA A. You would qualify as an urgent care if: Ⅲ your office advertises walk-in services to the public Ⅲ your office operates a center that offers walk-in care to patients at all times that you are open 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 | M a y 2 0 0 8 31