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DAVID STERN, MD (Practice Velocity)
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 different fee schedule?

Question submitted by Nicole Phelps,
First Health Medical, Fresno, CA
A.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 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
  • 99051: You may use this code for evening, weekend, and holiday 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 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 be substantially higher than the copay for a visit to a primary 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 Centers for Medicare & Medicaid Services’ Documentation Guidelines for E&M Services as a basis for E&M code selection and physician/non-physician practitioner documentation 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 advantageous 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, however, is reluctant to consider using the 1995 guidelines.

Q. I am wondering if the Urgent Care Association has an opinion on this issue. I have searched your website but cannot find anything of this nature. If UCA does have an opinion, I am sure it would be an important contribution to our local discussion.

Question submitted by Judith M. Carr, CPC, Optimum Physician Services Corp., Queensbury, NY
A.UCA does not have an official position on this coding 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 virtually 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.

The 1997 guidelines have several problems:

  • They are virtually impossible for a physician to master due to the scores of bulleted items that are only valid for certain types of exams (examples: musculoskeletal eye vs. genitourinary, etc.)
  • The 1997 guidelines generally work with specialized electronic medical records systems or with multiple pre-formatted templates that include the required It is virtually impossible to accurately extract the 1997 bullets from a dictated chart; if this extraction is done, physicians will invariably not document to appropriate levels due to the punctilious specificity of the bullets.
  • When followed to the letter, the 1997 guidelines reduce revenue by making a truly compliant comprehensive exam virtually impossible in the real world of medical When I fully explained what a comprehensive general multisystem exam entails as defined by the guidelines, one physician exclaimed, “Why, no doctor ever does all that!”

Using both sets of guidelines can bring improved revenue to urgent care centers. Thus, it makes sense to be aware that, for any given chart, the guidelines that you use may often make a significant difference in the final E/M code.

As a consultant, you are merely suggesting that the hospital follow accepted best practices. Since this hospital ad- ministration (on the advice of one or two well-meaning coders) is deviating from generally accepted practice, I would encourage you to ask the administration for a statement from some official organization that recommends that hospitals deviate from CMS’s official position.

Q.How does one code for a one-view radiograph of the thoracolumbar spine? The code (72080) clearly states that it includes “two views.” In the past, we marked the actual number of views and then appended modifier-52 (reduced services). Is this correct or is there another code that we should use?
Question submitted by Julie Gretchmann, Physicians Immediate Care, Rockford, IL

A.You have been coding correctly. Another way to code this would be using an “unlisted services” code. But this would require appending documentation, and reimbursement would be hit or miss, depending on the payor.
Note: CPT codes, descriptions, and other data only are copyright 2007 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.

Choosing the Right Fee Schedule— and the Right Resource

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine