DAVID STERN, MD (Practice Velocity)
Q. If a practice buys or opens an urgent care facility that is not in a hospital nor affiliated with a hospital, should we be using routine E/M codes for our visits? Secondly, do we have to follow the Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines?
A. Yes. You should use the same E/M codes as used by the physician offices (990201-99215). EMTALA does not apply to urgent care centers that are not in a hospital nor affiliated with a hospital.
Q. Can an urgent care center and a hospital emergency department exist in close proximity to each other and/or be located in a combined facility?
A. Yes. Many hospitals set up a “fast track” program as part of the hospital emergency department (ED) to treat cases that are found to be relatively minor on triage. Because the fast tracks are actually a part of the ED, fast tracks generally code and bill as an ED.
As for urgent care on campus, as long as the urgent care does not share a common entrance to the hospital ED, it seems reasonable to operate the urgent care and bill as an urgent care center (POS 22: outpatient hospital). Many hospitals err on the side of caution and stay under EMTLA guidelines.
Q. Our organization has two family practices and an urgent care that all operate under the same Tax Identification Number (TIN). If a patient on the family practice is seen in the urgent care, are they billed as an established patient even if it is the initial visit to a different practice within the group?
A. Yes. The patient is coded as an established E/M code if the patient has received services within the past 3 years at any location of the group (either primary care or urgent care) by any physician of the same specialty.
Q. If a patient is seen at a different location by the same provider, can we bill it as an initial visit?
A. The general answer is that you must code with an ESTABLISHED patient E/M Code.
You must code with an ESTABLISHED patient E/M code when any of the following apply:
- The patient has received services from this particular physician in any setting (ED, other practice, nursing home, etc.) within the past 3 years.
- The patient has received services in the practice (at any location) from a physician of the same specialty within the past 3 years.
However, you can bill a NEW patient E/M code, if any one of the following criteria apply:
- The patient has not received physician services from the practice within the past 3 years.
- The patient has not received physician services in this clinic within the past 3 years and the clinic operates a separate practice under a different TIN from any other clinic where the patient has not received physician services within the past 3 years.
- The patient has not seen a physician of the same specialty (as the visit) in the same practice within the last 3 years.
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 legal advice.