DAVID STERN, MD (Practice Velocity)
Q. Is there a benchmark for E/M codes in the urgent care setting? For instance, are there a certain percentage of 99213 vs. 99214 for established patients? Currently out urgent care providers’ coding is being compared to CMS Family Practice standard.
A. To my knowledge, there is no published information detailing E/M distribution for urgent care facilities. If there was, however, it would simply document what was actually being coded by urgent care facilities. We know from multiple studies that provider coding is quite inaccurate; 30% to 50% of charts are miscoded. Thus, just as with the family practice data, it is much better to audit your charts and know for certain that your providers are coding compliantly, based on both documentation and medical necessity.
Q. Can you charge for braces, wrist splints, and slings with L codes in an urgent care center or do you need a different Place of Service code? One of our payors said to use POS-12 and E/M POS-11.
A. Using Place of Service code 12 (Home) is not a typical approach to bill out orthopedic supplies for an urgent care facility. However, payors sometimes make their own unique and sometimes inexplicable rules. Before you bill using this method, you may want to request this directive in writing form the payor.
Q. There is a specific benefit for urgent care facilities identified via the Place of Service code 20 (urgent care facility). It seems most urgent care centers bill with a Place of Service code 11 (office), which pays a lesser benefit. Is there a reason most, if not all, urgent care centers do not bill with a Place of Service code of 20 instead of 11?
A. The specific required Place of Service code is generally the choice of the payor.
Q. Can an urgent care center that is billing only Professional Fee billing use a POS code 11 (Office)?
A. Generally, an urgent care center that bills a professional fee only (on CMS-1500) and the “facility” fee (on UB-04) will be billing this way because it operates as an outpatient department of the hospital. The typical Place of Service code would be POS-22 (outpatient hospital).
A physician office (POS-11) or an urgent care facility (POS-20) would not be considered part of a hospital, so it would not generally be appropriate to use these POS codes for an urgent care center that bills the professional and “facility” components separately. Normally the payor’s software will not properly process separate CMS-1500/UB-04 claims for a clinic with a code POS-11. The expected edit would be to deny the facility fee UB-04 and pay on the professional fee CMS-1500. If the payor paid on both, it would have a compliance issue that might result in accusations of fraud or large refunds to the payor.
However, the caveat that always applies is this: As long as you clearly communicate with the payor as to the nature of your facility, the payor may choose to ask you to bill with any POS code. If you deviate from the norm, it is a good idea to specify the nature of the facility and to get the directive in writing. Should the payor’s corporate memory fade, you will have a written directive to back up your particular procedure.
Note: CPT codes, descriptions, and other data only are copyright 2011, American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.