Q. I am reviewing documentation for a freestanding urgent care center that performs pulse oximetry on every patient they see, regardless of the reason. Is this typical? In some cases, they are billing the case rate code, S9083. Please let me know if this is standard operating procedure.
A.Medicare will allow payment for pulse oximetry under two conditions: 1) when it is linked to an appropriate diagnosis code; and 2) if it considered as being “reasonable and necessary.” Examples of few instances in which you would bill are when a patient exhibits signs or symptoms of respiratory or cardiac dysfunction or when the diagnosis is a cardiopulmonary disease. You would bill CPT code 94760, “Noninvasive ear or pulse oximetry for oxygen saturation; single determination” for a single instance, or CPT code 94761 for multiple determinations when warranted.
If you are billing a case rate code, such as S9083, “Global fee urgent care centers,” you would not bill the code(s) for pulse oximetry unless this was a code that was negotiated for payment in addition to the case-rate payment
Q. Can an urgent care center bill for oral medication such as Ibuprofen or Tylenol when given to a patient at the time of the visit? Also, we purchase emergency inhalers to give to patients seen when pharmacies are closed. Can we charge patients for the inhalers?
A.Typically, payors will not reimburse the expense for oral medication given to a patient even though there are HCPCS codes available for oral medication (e.g., S0119, Ondansetron, S5000, “Prescription generic drug,” S5001, “Prescription brand name drug,” or J8499,”Prescription drug, oral, nonchemotherapeutic, NOS, etc.”). You can bill the patient for medication given in the office as long as the drugs were not samples provided to you by a pharmaceutical company. If you are unsure of a payor’s policy, you should check with the payor in question.
On the subject of dispensing an inhaler, it would be no different than dispensing any other prescription medication. Dispensed prescription medications are generally not reimbursed by payors, unless you have set up an arrangement to essentially bill as a pharmacy to the patient’s prescription insurance plan. There are a few pre-packaged dispensing companies that offer this service. However, reimbursement is minimal and often quite delayed. Thus, most clinics offer this service only on a cash basis.
In the case of an emergency, you would generally treat and bill for aerosolized inhalation treatment. The patient must be stable (i.e., not in need of immediate additional treatments) before discharge. Thus, unless you are in a rare community that does not have a pharmacy with extended hours, you should usually be able to send the patient to a pharmacy to pick up the inhaler.
DAVID STERN, MD (Practice Velocity)
