DAVID STERN, MD (Practice Velocity)

Q. Can physicians see regular patients and schedule routine care at urgent care facilities? If so, can the urgent care center bill for those services at a separate, lower rate than the urgent care rate?

A.Special attention should be paid to payor contracts in these situations. If the insurance company views your patient’s visits as urgent care even though you provided primary care, the patient could be responsible for higher urgent care copays or even urgent care deductibles. You would want to check with the payor to see if you must always collect urgent care copays. Some urgent care contracts state that follow-up visits should be handled by a patient’s primary care provider, so providing primary care services could be a violation of your contract.

If an urgent care provider wants to provide primary care, I would recommend starting a new business with a new TIN incorporated as a PC, LLC, or PLLC, depending on your state. New payor con-tracts will also need to be initiated and there is the possibility of running into an issue where a certain payor may not allow you to do urgent care while operating a primary care facility.

You would want to seek legal counsel before making any changes because certain provisions of the federal Stark law could make it illegal to refer from an urgent care practice to primary care if any owner of the urgent care also has an owner- ship stake in the primary care. A few states have additional laws that are similar to Stark that may apply to all carriers and may be even more restrictive.

Once your business is set up and tax documents are in place, you will want to begin the contracting and credentialing process. Although some urgent care contracts may not require you to credential all of your providers, it is very likely you will have to individually credential all of your providers who render primary care services.

If providing primary care in an urgent care center is the direction you take, it is also important to have specific guidelines for your front desk staff so that they know the differences in handling transactions between primary and urgent care visits. For example, collecting the correct co-pays and reporting visits appropriately to your billing staff.

Q. Would we bill with Outpatient E/M codes 99201-99215 if we are a walk-in practice that does not qualify as a true urgent care center?

A.E/M services are categorized into different settings, depending on where the service is furnished. However, forE/M services in an outpatient or other ambulatory facility (including a walk-clinic, primary care practice and an urgent care center), CPT codes 99201-99205 are used to report evaluation and management services for a new patient. Use codes 99211- 99215 for established patients in this same type of setting.

Q. Can we bill both the S9088 and 99051 on same visit for our urgent care visits?

Yes, you can bill both codes for the same visit along with the E/M code. HCPCS code S9088, “Services provided in an urgent care center (list in addition to code for service),” is specifically for use in an urgent care center. You would bill this code for every visit. Keep in mind that Medicare does not recognize this code at all so you would bill it to all payors except Medicare.

CPT code 99051, “Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service,” is another code that could be billed to insurances, with the exception of Medicare. Evening hours are generally considered to start at 5 p.m. This code was designed to compensate your practice for the additional costs of being open extended hours. This code is typically billed to patients seen after 5 p.m. Monday through Friday and all day on Saturday, Sunday, and federal  holidays.

Check the policies of each of your payors for both of these codes to see if you can receive compensation from them. Try to include reimbursement fees for these codes as well when negotiating contracts.

Q.Can S9088 be used with  an E/M code?

A.Any urgent care center can use code S9088, “Services provided in an urgent care center (list in addition to code for service).” This code is an add-on code, so it cannot be billed alone. However, you would not bill the code to Medicare, since it is not covered. You will also want to check state regulations as well as payor contracts to see whether this code should be billed or not.

An urgent care center, as defined by the Urgent Care Association of America, is a walk-in medical clinic (offering at least plain-film radiology and CLIA-waived labs) that is open to the public for walk-in, unscheduled visits during all open hours and offering significant hours beyond the typical 9:00 a.m. to 5:00 p.m., Monday through Friday. Some payors have outlined more specific requirements, including ACLS-certified personnel, on-site inspections, crash cart with specific supplies, and facility credentialing. Make sure you check for any specific requirements in your state.

Q. Can 95992 be billed with an E/M code on the same day of service?

A.Even though CPT code 95992, “Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver, per day,”) was added in 2009, only Physical Therapists could be reimbursed for the code and physicians had to report the procedure using an E/M code until 2011. Now physicians may also bill this code for the procedure. An Audiologist may not bill the code since it is considered a therapeutic procedure.

If, during an office visit, it is determined that the procedure needs to be performed on the same day as the visit, you may code an E/M in addition to the procedure. You would append modifier -25, “Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service,” to the E/M code. Alternatively, if it was determined at a prior visit that the patient needed the procedure performed and was returning for the procedure, you would only bill CPT 95992 because the evaluation and management was done at a prior visit.

Q. Can my facility bill for a penicillin injection? If so, what is the code and pricing? Do I need to use a modifier?

A.There are several types of penicillin that could be billed:

  • Penicillin G Benzathine 100,000 Units     J0561
  • Penicillin G Benzathine and Penicillin G Procaine    100,000 Units   J0558
  • Penicillin G Potassium 600,000 Units     J2540
  • Penicillin G Procaine 600,000 Units     J2510

For each of the HCPCS codes listed above, you would bill the administration code 96372, “Therapeutic, prophylactic, or di- agnostic injection (specify substance or drug); subcutaneous or intramuscular.” If 1.2 Million Units of Penicillin G Benzathine was administered, you would bill HCPCS code J0561 at12 units and CPT code 96372.

You will want to charge a price based on cost to you, and you might also want to get reimbursement values from some of your major payors to see how well the specific medication is reimbursed. You will need to submit the NDC code to bill for the medication. If a separate E/M service was performed, you would bill the appropriate E/M code with a modifier -25, “Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.” Keep in mind that some payors will bundle the injection code into the E/M service (or flat rate service), so be sure to check payor agreements and payor policies.

Primary Care in the Urgent Care Setting, E/M Codes With Other Services, Penicillin Injection

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
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