Q. We sometimes have patients come in to our urgent care center with an insurance payor that we do not have a contract with. We do not want to turn them away, but we do want to guarantee our payment. Do we have to submit a claim to the insurance company in such cases? Currently, we offer these patients a self-pay discount, and they pay us in full at the time of service. A. Typically, …
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February 2015
Fracture Codes, Strapping and Splint Application Codes, S9088 Code
Q. When is it appropriate to use fracture codes without manipulation? If a patient comes in with pain in a finger after a fall and an evaluation and management is performed, x-rays are taken to confirm a fracture, the finger is splinted, and the patient is referred to an orthopedist, would that treatment constitute billing for fracture care? If not, what must we do to be able to bill these? A. CPT suggests that only …
Read MoreRevenue Per Patient, Prescription Drug Management for MDM, Medicare and HCPCS J3301 Denials
Q. What is an acceptable income per patient visit for an urgent care clinic? A. The recent benchmarking survey completed by the Urgent Care Association (UCA) found that the average urgent care center collects $110 per patient. However, the “acceptable” net revenue per patient visit varies widely from center to center and state to state. It fluctuates based on many variables: Existing contracts from payors State (e.g., payors in California and Arizona typically have lower …
Read MoreWorkers’ Compensation Visits, Cerumen Removal
Q. I have a question on coding Workers’ Compensation claims. I work in a hospital system and hospital coders oversee our charts. I feel they under code for the work we do. They are afraid of audits and refusal to pay. Typically, they will return the chart so that I can document my time and then they will charge for the time spent instead of the documentation. I’m told there are no “bullet points” or …
Read MoreNew CMS Modifiers, Urgent Care Codes, Supply Codes
Q. What will be the impact of use of the new HCPCS modifiers related to modifier -59 beginning January 1, 2015? A. CMS recently announced the creation of four new HCPCS modifiers that will further refine modifier -59, “Distinct procedural service.” According to CMS, modifier -59 is the most widely used modifier, and it is being used inappropriately in most cases. Adding modifier -59 indicates that a code represents a service that is separate and …
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October 2014
Workers’ Compensation, Medicare and S Codes
Q. The following example is a common occurrence in our urgent care center when billing workers compensation (WC) claims: Patient A comes to the urgent care center for treatment of injuries sustained while on the job with Employer B. Patient A says, “My boss sent me here because it was close.” Now, Patient A has no insurance, no claim number, and no authorization for treatment, just his employer’s name and a supervisor’s name. Who is …
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September 2014
E/M for Sinusitis and Pharyngitis
Q. The clinic I work at uses 99214 for most patients (50%) for sinusitis and pharyngitis. Is this a common code to use for these problems? A. The E/M levels of services recognize sevencomponents: History Examination Medical decision making Counseling Coordination of care Nature of presenting problem Time The history, examination, and medical decision making are considered to be the key components in selecting a level of E/M service. Counseling, coordination of care, and the …
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