Having worked with both Emergency Department (ED), Providers and Urgent Care Providers, there is a definite difference in approaches with patient assessment between the two specialties. I have found that many ED Providers often felt that close to every case was a Level 5, or in fact, Critical Care (CC), which, unless it’s a Trauma Center, those levels of care, are not usually the typical case. On the other hand, I find that Urgent Care Providers often seem stuck in the “Three’s” as I call it and often under code their cases. Over coding and Under coding can cost a practice dearly in revenue and put it at a compliance risk, in the event of a payer audit. Government Payers like CMS do not approve of either over coding or under coding, as they both cost the healthcare system millions each year and can misrepresent a patient’s true healthcare status.
Urgent Care has seen updates and changes, to documentation, so it is mission critical that Urgent Care Providers are aware of these updates, as well as Coders and Billers within their practices. It is an opportunity to streamline overall practice operations and ensure proper reimbursement, avoid under and over coding, as well as to maintain Compliance.
Let’s Talk Time:
EM visit level selection is based solely on medical decision-making (MDM) or total time
Time has moved from face-to-face time for EM codes 99212-99205 to a “minimum time” per the CPT Editorial Panel. Time ranges have been eliminated in lieu of the minimum total time requirement. See below graphic from the AAPC:
Click here to go to the AAPC time grid for 2024: https://www.aapc.com/blog/88921-cpt-2024-brings-more-e-m-changes/
Let’s Talk MDM:
Medical Decision Making, MDM, has been overhauled several times since 2021 from CMS, AMA and CPT and is now the predominant EM visit component, unless you are using minimum overall time, as indicated above. There is a new AMA MDM Grid for from NAMAS (National Alliance of Medical Auditing Specialists), for 2023-2024, along with updates (see below link to NAMAS grid), Below are several areas where MDM has been updated:
Revisions to Office/ Outpatient EM code descriptors – 99211-99215 and 99202-99205
ROS is no longer required
The EM level is determined by a combination of Problem Acuity/Data/Risk
Updated MDM grid comprised of 5 columns with the first two indicating EM Code and the Level of Service, and final three indicating each of the three elements that can be scored (Number & Complexity of Problems Addressed, Work Performed & Analyzed during the visit, and lastly, Risk of Complications and/or Morbidity or Mortality of Patient Management)
EM Visit Codes are now comprised of 99212-99205, as 99201 was eliminated, so levels are 2-5 New or Established, instead of 1-5 (99211 is still primarily a Nurse Visit).
Level of Service is defined as: Straightforward, Low, Moderate, High
Number and Complexity of Problems Addressed is defined as: Minimal, Low, Moderate or High
Complexity of Work/Data is defined as: Minimal or None, Limited, Moderate, Extensive and includes a review of unique test results prior to visit, Ordering unique tests at current visit, Assessment by independent historian, independent interpretation of tests Discussion notes
Risk is defined as: Negligible Risk, Average Risk, Above Average Risk
We know that History and Exam components are no longer used for EM level selection, but they are still essential data areas of the overall note that provide important information support criteria for MDM selection, as MDM extrapolates that data and uses it towards “Leveling” a patient visit
You can find an updated AMA MDM grid free for 2023-2024, by clicking on the following link to NAMAS (National Alliance of Medical Auditing Specialists): https://shop.namas.co/FREE-Revised-MDM-Chart-Office-Based-Service_p_735.html
Documentation, Coding and Billing Tips:
The first detail in a note should be the documentation of the Chief Complaint
Perform a medically appropriate History and/or Physical Examination in detail. Now, as it states, either or a medically appropriate history or physical exam, but personally, I advise my providers/clients to do both, as it provides more information in the event of a retrospective audit or request for records and is overall a better insurance against potential liability.
Document all diagnostic tests and results in the note and ensure the copy of the order is in the EMR
Document the Assessment and Treatment plan in detail and how the patient responded to any treatment provided during the encounter.
Ensure proper use of supported CPT Codes, Diagnosis Codes, HCPCs Codes, and Modifiers based on documentation in the encounter.
Top Urgent Care Codes:
S9083 Global fee urgent care center
S9088 Evaluation & treatment of medical conditions and is an “add-on” code for Urgent Care
99202-99205: Evaluation & Management of New Patients
99212-99215: Evaluation & Management of Established Patients
99211 – Nurse Visit
12001-13160: Wound Repair
10060-10180: Incision & Drainage
20525-20553: Foreign Body Removal
29000-29799: Splint and Cast Applications
Chest Xray – 2 views 71046
EKG – 93000
Exclusive ‘S’ Codes for Urgent Care
Both Urgent and Primary Care have been using Codes from Healthcare Common Procedure Coding System (HCPCS). Usually, both urgent care and normal health facilities treat the same medical issues, so they often follow the same coding system. So, to overcome this issue, codes starting with the letter ‘S’ were introduced specifically for urgent care facilities and are as follows:
S9083 Global fee urgent care center: Is commonly used in Urgent Care practices and is exclusive to this specialty. It is used instead of an EM code and is usually the only code billed, as it is a Global Code or Case Rate Code and encompasses all charges for services rendered that day to a patient, unless there are some pre-negotiated carve outs in a payer contract. In this case, you may be able to bill for additional charges, such as Xray’s or Laceration repairs etc. Many Payers prefer to reimburse Urgent Care in this manner, as it allows the payer to group all services provided during an urgent care visit, regardless of complexity, work and risk to manage that patient’s care.
Since S9083 is reimbursed with a flat rate, regardless of the number of services provided the day of the visit, and regardless of level of care, it is usually recommended for smaller practices. Most Urgent Care Centers handle a variety of cases and usually include some higher levels of care, so if many of the payer contracts have case rates with S9083, it can prove difficult to remain financially solvent, as costs will often run higher than reimbursement rates to care for patients.
S9088 is used for the Evaluation & treatment of medical conditions and is an “add-on” code to allow urgent care centers to be reimbursed for at least a portion of this increased cost of rendering service. Unless restricted by contract or regulations, you should add this code to all other billed codes. As an add on code, it can’t be billed separately and is used in conjunction with EM codes 99212-99205. Generally, medical services provided at an Urgent Care center are significantly higher in cost versus Primary Care, Family Medicine and Internal Medicine, but is far less costly to a payer than sending a patient to the ED or if the patient shows up at the ED. So S9088 when used as an add on code, is certainly worth negotiating into payer contracts to assist with the increased cost of doing business in an urgent Care and will cost the payer far less for the patient to be treated at Urgent Care than the ED.
Take Away:
As Urgent Care centers have become more popular, it is paramount that a practice is able to operate at an exclusive and superb level of care, like an ED, they treat walk ins, as there usually are no scheduled follow up appointments, so there is no prior way to know what the patient is presenting with. So, it is critical to ensure they are able to provide such top notch care on a moment’s notice, that Payers must be negotiated with as well as ensuring Providers and staff have the necessary tools at the ready to accurately document and code patient encounters and are given ongoing training for documentation improvement to keep them abreast of the changes in healthcare that impact Urgent Care.
RESOURCES:
https://www.ama-assn.org/system/files/2023-e-mdescriptors-guidelines.pdf
https://www.cms.gov/files/document/2023-official-icd-10-pcs-coding-guidelines.pdf
https://www.jucm.com/practice-management-articles/
https://www.linkedin.com/pulse/urgent-care-billing-5-kpis-you-should-analyze-tcmxc/
MBR AAPC/NAMAS
Director of Compliance and Education, ZENMED Solutions INC.
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