{"id":1735,"date":"2024-07-23T06:09:57","date_gmt":"2024-07-23T06:09:57","guid":{"rendered":"https:\/\/zenmedinc.com\/blog\/?p=1735"},"modified":"2024-12-07T13:08:15","modified_gmt":"2024-12-07T13:08:15","slug":"mdm-updates-and-more-for-urgent-care-2024","status":"publish","type":"post","link":"https:\/\/zenmedinc.com\/blog\/mdm-updates-and-more-for-urgent-care-2024\/","title":{"rendered":"MDM UPDATES AND MORE FOR URGENT CARE 2024"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"1735\" class=\"elementor elementor-1735\">\n\t\t\t\t<div class=\"elementor-element elementor-element-58d4cc4 e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"58d4cc4\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e5ae80d elementor-widget elementor-widget-text-editor\" data-id=\"e5ae80d\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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\u2019s 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 \u201cThree\u2019s\u201d 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\u2019s true healthcare status.<\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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.<\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Let\u2019s Talk Time:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">EM visit level selection is based solely on medical decision-making (MDM) or total time<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Time has moved from face-to-face time for EM codes 99212-99205 to a \u201cminimum time\u201d per the CPT Editorial Panel. Time ranges have been eliminated in lieu of the minimum total time requirement. See below graphic from the AAPC:<\/span><\/span><\/p><\/li><\/ul><p><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter size-full wp-image-1740\" src=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/08\/urgent-care.png\" alt=\"\" width=\"474\" height=\"244\" \/><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Click here to go to the AAPC time grid for 2024: <\/b><\/span><\/span><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.aapc.com\/blog\/88921-cpt-2024-brings-more-e-m-changes\/\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>https:\/\/www.aapc.com\/blog\/88921-cpt-2024-brings-more-e-m-changes\/<\/b><\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Let\u2019s Talk MDM:<\/b><\/span><\/span><\/p><p><span style=\"font-family: Times New Roman, serif; color: #000000;\"><span style=\"font-size: medium;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">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 <\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>(National Alliance of Medical Auditing Specialists), <\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">for 2023-2024, along with updates (see below link to NAMAS grid), Below are several areas where MDM has been updated:<\/span><\/span><b> <\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Revisions to Office\/ Outpatient EM code descriptors &#8211; 99211-99215 and 99202-99205 <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">ROS is no longer required<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">The EM level is determined by a combination of Problem Acuity\/Data\/Risk<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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 &amp; Complexity of Problems Addressed, Work Performed &amp; Analyzed during the visit, and lastly, Risk of Complications and\/or Morbidity or Mortality of Patient Management)<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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).<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Level of Service is defined as: Straightforward, Low, Moderate, High<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Number and Complexity of Problems Addressed is defined as: Minimal, Low, Moderate or High<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Times New Roman, serif; color: #000000;\"><span style=\"font-size: medium;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">Risk is defined as: Negligible Risk, Average Risk, Above Average Risk <\/span><\/span><\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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 \u201cLeveling\u201d a patient visit<\/span><\/span><\/p><\/li><\/ul><p><img decoding=\"async\" class=\"aligncenter size-full wp-image-1738\" src=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/08\/urgent-care-2.png\" alt=\"\" width=\"1186\" height=\"824\" srcset=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/08\/urgent-care-2.png 1186w, https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/08\/urgent-care-2-300x208.webp 300w, https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/08\/urgent-care-2-1024x711.webp 1024w, https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/08\/urgent-care-2-768x534.webp 768w\" sizes=\"(max-width: 1186px) 100vw, 1186px\" \/><\/p><p><span style=\"font-family: Times New Roman, serif;\"><span style=\"font-size: medium;\"><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">You can find an updated AMA MDM grid free for 2023-2024, by clicking on the following link to <\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>NAMAS (National Alliance of Medical Auditing Specialists): <\/b><\/span><\/span><\/span> <span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/shop.namas.co\/FREE-Revised-MDM-Chart-Office-Based-Service_p_735.html\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/shop.namas.co\/FREE-Revised-MDM-Chart-Office-Based-Service_p_735.html<\/span><\/span><\/a><\/u><\/span><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Documentation, Coding and Billing Tips:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">The first detail in a note should be the documentation of the Chief Complaint <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Document all diagnostic tests and results in the note and ensure the copy of the order is in the EMR<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Document the Assessment and Treatment plan in detail and how the patient responded to any treatment provided during the encounter. <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Ensure proper use of supported CPT Codes, Diagnosis Codes, HCPCs Codes, and Modifiers based on documentation in the encounter. <\/span><\/span><\/p><\/li><\/ul><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Top Urgent Care Codes:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">S9083<\/span><\/span><b> <\/b><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">Global fee urgent care center<\/span><\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">S9088 Evaluation &amp; treatment of medical conditions and is an \u201cadd-on\u201d code for Urgent Care<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">99202-99205: Evaluation &amp; Management of New Patients<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">99212-99215: Evaluation &amp; Management of Established Patients<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">99211 \u2013 Nurse Visit <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">12001-13160: Wound Repair<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">10060-10180: Incision &amp; Drainage<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">20525-20553: Foreign Body Removal<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">29000-29799: Splint and Cast Applications<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Chest Xray \u2013 2 views 71046<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">EKG &#8211; 93000<\/span><\/span><\/p><\/li><\/ul><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Exclusive \u2018S\u2019 Codes for Urgent Care<\/b><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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 \u2018S\u2019 were introduced specifically for urgent care facilities and are as follows:<\/span><\/span><\/p><p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>S9083 Global fee urgent care center<\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">: 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\u2019s 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\u2019s care.<\/span><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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.<\/span><\/span><\/p><p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>S9088 is used for the Evaluation &amp; treatment of medical conditions and is an \u201cadd-on\u201d code to allow urgent care centers to be reimbursed for at least a portion of this increased cost of rendering service. <\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">Unless restricted by contract or regulations, you should add this code to all other billed codes. As an add on code, it can\u2019t 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. <\/span><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Take Away:<\/b><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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\u2019s 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. <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>RESOURCES:<\/b><\/span><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.ama-assn.org\/system\/files\/2023-e-mdescriptors-guidelines.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.ama-assn.org\/system\/files\/2023-e-mdescriptors-guidelines.pdf<\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cms.gov\/files\/document\/2023-official-icd-10-pcs-coding-guidelines.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cms.gov\/files\/document\/2023-official-icd-10-pcs-coding-guidelines.pdf<\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cms.gov\/outreach-and-education\/medicare-learning-network-mln\/mlnproducts\/downloads\/eval-mgmt-serv-guide-icn006764.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cms.gov\/outreach-and-education\/medicare-learning-network-mln\/mlnproducts\/downloads\/eval-mgmt-serv-guide-icn006764.pdf<\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.jucm.com\/practice-management-articles\/\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.jucm.com\/practice-management-articles\/<\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.linkedin.com\/pulse\/urgent-care-billing-5-kpis-you-should-analyze-tcmxc\/\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.linkedin.com\/pulse\/urgent-care-billing-5-kpis-you-should-analyze-tcmxc\/<\/span><\/span><\/a><\/u><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>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),<\/p>\n","protected":false},"author":2,"featured_media":1782,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[16],"tags":[39,20,21,19],"class_list":["post-1735","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicare","tag-em-documentation","tag-mdm","tag-medical-decision-making","tag-urgent-care"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>MDM UPDATES AND MORE FOR URGENT CARE 2024 - ZenMed Solutions Inc<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/zenmedinc.com\/blog\/mdm-updates-and-more-for-urgent-care-2024\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"MDM UPDATES AND MORE FOR URGENT CARE 2024 - ZenMed Solutions Inc\" \/>\n<meta property=\"og:description\" content=\"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. 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