CODING Q&A Choosing the Right Fee Schedule— and the Right Resource ■ DAVID STERN, MD, CPC Q . My office has started to provide urgent care. Should these services be reimbursed at a higher price than for our family practice services? Is there a dif- ferent fee schedule? Question submitted by Nicole Phelps, First Health Medical, Fresno, CA A. Ⅲ Ⅲ Ⅲ Ⅲ Ⅲ Ⅲ Here is the scoop on coding and reimbursement for urgent care: Some payors will pay more for urgent care services over primary care services, but you will almost cer- tainly need to operate under a separate taxpayer iden- tification number. You may need to negotiate and/or ed- ucate payors to get higher rates. Many payors will not pay more for urgent care (some may even want to pay less). Medicare will not pay more for urgent care. 99051: You may use this code for evening, weekend, and holiday reimbursement. Many payors do not pay. You may need to share with them the fact that you in- cur significant increased costs (in downtime and em- ployees requiring higher wages) by operating during off- hours. S9088: You may add this code to existing codes for serv- ices that you provide in an urgent care center. Some payors will pay an additional amount. You may need to educate the payors as to the increased costs that you in- cur in rendering true urgent care services. Urgent care copay: If you bill as an urgent care center, some payors may require you to collect the copay for ur- gent care as listed on the insurance card. This copay may 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 be substantially higher than the copay for a visit to a pri- mary care physician. Payors use this higher copay as a disincentive for patients to utilize urgent care services. Q . I am consulting with a hospital regarding coding practices at their hospital-owned urgent care centers. At issue is the use of the 1995 vs. the 1997 Cen- ters for Medicare & Medicaid Services’ Documentation Guidelines for E&M Services as a basis for E&M code se- lection and physician/non-physician practitioner docu- mentation education. The American College of Emergency Physicians strongly recommends the use of the 1995 guidelines for coding, as they are more beneficial to reimbursement in the emergency department setting. The providers who staff our urgent care centers also staff our ED. I would anticipate that at least some of the issues making the 1995 guidelines more advan- tageous would apply as well in the urgent care setting. Even CMS clearly directs its carriers to conduct reviews using both the 1995 and the 1997 guidelines “(whichever is more advantageous to the physician)....” The hospital, how- ever, is reluctant to consider using the 1995 guidelines. I am wondering if the Urgent Care Association of Amer- ica has an opinion on this issue. I have searched your web- site but cannot find anything of this nature. If UCAOA does have an opinion, I am sure it would be an important contri- bution to our local discussion. Question submitted by Judith M. Carr, CPC, Optimum Physician Services Corp., Queensbury, NY A. UCAOA does not have an official position on this cod- ing issue. I suspect that this is because CMS has a clearly stated position (that the physician may use either ’95 or ’97 guidelines), and this position is widely accepted by vir- tually all payors. The physician is not even required to state which set of guidelines was used to code any particular visit, and CMS has clearly indicated that the physician may switch between 1995 and 1997 guidelines from chart to chart. 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 | J u l y/A u g u s t 2 0 0 8 35