Coding Q&A

Q: I plan to hire physician assistants and other nonphysician providers in my urgent care clinic. I understand that I can use “incident to” billing to have their patient visits reimbursed at the physician rate. What are the rules for “incident-to” billing? A: The Centers for Medicare and Medicaid Services (CMS) defines “incident to” as “those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.” Services must be provided byRead More
Q: Should patient accounts ever get turned over to a collection agency? A: The altruistic nature of running an urgent care center—to serve the public—can make it difficult to send patient accounts to collection, but it must be done if you want your center to survive. Some urgent care centers choose to leave patient balances in their billing systems indefinitely, but this puts a serious burden on the business by creating additional statement costs, wreaking havoc on financial reports, and inflating a center’s days in A/R. It also damages anRead More
Q: Are there specific requirements for Medicare wellness exams and who can perform them? A: Medicare offers an initial preventive physical examination (IPPE), which is also known as the “Welcome to Medicare” preventive visit or the annual wellness visit (AWV). Either a physician (a doctor of medicine or osteopathy) or a qualified nonphysician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist) can provide the services. The IPPE is a one-time initial examination that is covered within the first 12-month period after a participant is enrolled in PartRead More
There are 314 code changes in the CPT manual for 2018, with 172 new codes, 60 revised codes, and 82 deleted codes. Most of the changes affect surgery procedures, but the updates include several changes that are relevant to urgent care. For your convenience, we have listed these changes in expected relevance to urgent care: Radiology Codes for x-rays of the chest and abdomen have been deleted and replaced with codes based on the number of views; the guidelines give specific instruction on what has changed: New code 71045, “RadiologicRead More
Q: What is case-rate reimbursement, and how does it work in the urgent care sector? A: Case rate, sometimes called flat rate, describes a reimbursement structure in which providers receive a flat reimbursement rate for every patient visit, no matter what service they provide. Case-rate reimbursement means that the urgent care is contracted with the payor to receive the same reimbursement regardless of the acuity of care, whether it’s the treatment of a hangnail or a complex laceration repair. Q: Will the simplification of case-rate reimbursement mean that my centerRead More
Q: Do you have information on the 2017-2018 influenza vaccine codes? A: The American Medical Association (AMA) recently published a list of new and revised vaccine codes on their website ( These codes will be published in the 2018 Current Procedural Terminology (CPT) manual. The two new influenza vaccines on the list are: 90682, “Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use” 90756, “Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage,Read More
Q: What can we bill for when we give a patient a nebulizer treatment for an acute airway obstruction during an exacerbation of asthma, or wheezing due to an upper respiratory ailment? A: You can bill for the service and the medication. However, depending on the payer rules, the medication might be bundled into the service. Time is a factor when billing the service. If the treatment is less than 1 hour, you would bill Current Procedural Terminology (CPT) code 94640, “Pressurized or non-pressurized inhalation treatment for acute airway obstructionRead More
It’s again time to review what has changed with the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) effective October 1, 2017 through September 30, 2018. There are 360 new, 142 deleted, and 226 revised diagnosis codes in the final update. We will review the changes most relevant to urgent care, but the examples shown here are not all-inclusive. You can find all updates in the Centers for Medicare and Medicaid Services (CMS) website at Enterocolitis Code A04.7 was deleted to make room for two new codes thatRead More