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 responsible to pay the bill? How do we secure payment?
A. This is a common scenario in urgent care centers. One method for handling this would be to hand a phone to the patient and have the patient get the employer on the phone for you. This will allow you to get the information directly from the employer. If the patient is unable to get the employer on the line:
- You might decline to treat (assuming that it is not an emergency); or
- You might look at your loss history and if losses are small, establish a policy in advance to go ahead and treat employees in these scenarios.
This is a great opportunity for your urgent care center to build a relationship with the employer to provide occupational medicine services for their employees.
Q. How do you code for an urgent care visit and bill the urgent care portion to Medicare? Do you know how I can find Medicare reimbursement rates? If a Medicare patient is seen at an urgent care center, how do I bill for the physician portion and the facility portion separately? Would I use E/M codes or can we only bill the S codes assigned for urgent care? I heard that Medicare does not pay for S codes.
A. Urgent care billing and coding is unique. However, for Medicare, there are no special rules for urgent care as Medicare does not recognize urgent care as separate from any other outpatient physician office. If the patient is treated at an urgent care center, you bill E/M codes 99201-99215 as appropriate from the Office or Other Outpatient Services section of the CPT manual. You would also code (adding modifiers as appropriate) for any procedures performed during the visit.
S codes are never billed to Medicare. They have been requested by and are used exclusively by private sector payors.
To review reimbursement rates from Medicare, you can use the physician fee look up tool at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html, which provides help on how to navigate the site. There is also a link on that page that will provide you with even more information on how to use the search site at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How_to_MPFS_Booklet_ICN901344.pdf as well as the link for the fee schedule itself http://www.cms.gov/apps/physician-feeschedule/overview.aspx.
Q. How do we bill the urgent care codes S9083 vs. S9088? Can we bill E/M codes with the S codes?
A. HCPCS Code S9088, “Services provided in an urgent care center (list in addition to code for service)” can be billed to appropriate payors in an urgent care center. The S9088 code is billed in addition to the E/M code. As an add-on code, S9088 cannot be billed alone without an E/M code; therefore, you would bill E/M codes 99201-99215 as appropriate, along with any procedure codes if procedures were performed during the visit.
Some payors recognize that services rendered in an urgent care center cost significantly more than the services that are rendered in traditional primary care physician offices. This add-on code was designed to allow urgent care centers to be reimbursed for at least a portion of this increased cost of rendering service. You will want to check your contracts with other payors since this code might be bundled per your agreement with them.
HCPCS code S9083, “Global fee urgent care centers” is used in place of the E/M code. Depending on the specific payor contract, often it is the only code billed even when other services have been performed. This code is typically only used when it is required by a payor as a “case rate.” It bundles all services rendered in an urgent care visit into a single code, regardless of the complexity or number of procedures.
Case-rate coding is a good option for clinics that are prepared to care only for minor illnesses and injuries such as colds, insect bites, and minor bruises. However, if the urgent care is equipped to take care of many moderate-acuity injuries and illnesses (e.g., dehydration requiring intravenous fluids, fractures, complicated lacerations, corneal rust rings, and others), the S9083 reimbursement option is not ideal. If an urgent care is always reimbursed the same flat rate per patient, regardless of the actual cost of treating the patient, the urgent care is not rewarded for staffing the clinic with skilled physicians who can perform complex procedures. In reality, however, a significant number of national payors do not listen to this argument and will not allow any other billing method for urgent care.
DAVID STERN, MD (Practice Velocity)