DAVID STERN, MD (Practice Velocity)
Q. We have quite a few primary care physicians who regularly send patients to our urgent care center for x-rays. These patients have a prescription for the x-ray service, and they don’t want to be seen by the urgent care doctor.
I have several questions related to this service:
- Should we collect the urgent care copay (or) radiology imaging services copay (which is usually $0)?
- Should we code S9083 to payors whose contract states that the only contract we may bill is the urgent care global code – S99083?
- Should we add S9088 (services rendered in an urgent care center)?
- Should I use the same diagnosis code that the patient brings along with the script from the primary care doc for billing purposes?
- The urgent care physician does not see the patient face-to-face, but is the physician still responsible to read the x-ray?
Question submitted by John Whalen, Aloma Urgent Care, Florida
- In answer to your questions:
- Copay: Every payor is different, so you will have to check with each payor. Since you are contracted as an urgent care, payors may automatically apply the urgent care copay. You may, however, be able to get payors to waive this copay when only radiological services are performed. Contact each payor to understand their policy.
- S9083: Most payors may accept this code, especially since they usually have no way to see that no physician services were rendered by the urgent care center. The payor, however, is not likely to view this as the intended use of the code. Just billing the x-ray codes without having the payor change your setup is likely to result in denials.
Since their software is likely designed to allow only this code from your practice, you should contact the payor to see if they will allow you to bill radiological services, when this is the only type of service provided.
Some payors may refuse to pay for visits for radiological services only, as they will interpret the contract as offering reimbursement for urgent care services only. But with persistence on your part, most payors will be reasonable in finding a way to reimburse you for this important service to their members.
- S9088: Payors may reimburse you for this code, though doing so would not be consistent with the spirit of this code for this type of visit, as you are not actually rendering urgent care services. Such coding abuses often result in payors changing their policies and result in blanket denials for certain codes, even for urgent care centers that are using the codes as they were intended to be used.
- ICD-9: Yes, the diagnosis on the prescription is appropriate to use. You will want to be sure that the payor will cover the specific radiological service (i.e., reimburse for the CPT) when linked to that ICD-9 code.
- Professional fee: usually, the urgent care center will send these films to an outside radiologist, who will provide a reading back to the ordering physician and bill the appropriate CPT code with modifier -26 (professional component) to get reimbursed for the reading of the study. In this arrangement, you would code the CPT code with modifier – TC (technical component) to be reimbursed for the actual shooting of the film.
Q. Is it appropriate to use special after-hours coding (99051), if the appointment was scheduled prior to the date of service?
Question submitted by Annette Richardson, Mayo Hospital, ME
A. This coding method may fit into the strict definition of the code, but it does not seem to fit the intent of the rules. Payors that reimburse this for this code typically intend to reimburse urgent care centers for the additional expense of offering an alternative to the ED on evenings, weekends, and holidays. Payors are not generally intending to reimburse a practice simply for scheduling convenient hours for simple physician office visits.
You should check with each payor, but as a general rule I would discourage this practice, as abuses such as these tend to result in blanket charges of payor policies that end up being applied to practices that do code as intended by the payor for those codes.
Q. We offer pain management services, and we have started drug testing all patients upon their visit to our clinic. We are trying to bill Medicare for an E/M and a drug screen, using code G0431. The explanation for the denial is that the provider is not certified or eligible to be paid from this service. We have a CLIA number attached to the claim.
Question submitted by Tammy Scott
A. This question illustrates how complicated coding can be and how cryptic explanations of denial can be. The code G0431 became effective on January 1, 2010. Until April 1, 2010, however, CMS has instructed providers with a CLIA certificate of waiver to report CPT 80101QW. All other laboratory providers must report G0431. You may need to re-bill any claims for service dates between January 1 and March 31, 2010.
Note: CPT codes, descriptions, and other data only are copyright 2010, 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.