DAVID STERN, MD (Practice Velocity)
Q.For uninsured patients, how much discount should be given—70% off charges? Particularly in California.
A.It would be extremely rare to offer such a big discount to self-pay patients. It would be unadvisable for the following reasons:
- Unless your fee schedule is ridiculously high, you could not operate profitably at these
- Discounts should be given not for being self-pay, specif- ically, but for paying in full at time of
- You will need to watch out for accepting any fees that are below a Medicare fee schedule, as this may produce legal problems if you are participating in the Medicare
Q.Using diagnosis code V58.31 (encounter for change or removal of surgical wound dressing), can we bill the following codes?
- A6407 packing strips
- A4209 syringes
- A4550 surgical trays
- A4322 irrigation
- A6245 hydrogel
A.In general, these supplies are not billed by physician offices, as reimbursement for these codes is bundled into the fee for the actual CPT code of a procedure. These codes are usually billed by facilities (on the UB-04 form), where the relative value units (RVUs) for the procedure CPT codes are included.
In the outpatient physician office setting (i.e., the setting for billing for most urgent care centers), there are several situations that will come into play when considering this issue:
- Recheck of a wound that was sutured (or had an incision and drainage [I&D]) and is still within the global period (usually 10 days) for the procedure. In this case, it would not be appropriate to bill any of these codes, as all routine follow-up is included.
- Recheck of a wound that was repaired in another facility. If you did debridement, I&D, or some other procedure, then these codes would be included in the code for the procedure.
- If you used these supplies, but it was not during the global period for a procedure done at your center and it was not part of a procedure, then you may be able to code for these
- If you used these supplies and all the following criteria apply, then depending on the payor (but never for CMS payors), you may code for these supplies: The visit was during a global period, it was associated with a complication of that procedure, and it was not associated with another billable
NOTE: Just because you may compliantly code for certain supplies does not mean that a payor will actually reimburse for these supplies.
Q.We are an urgent care center in Georgia. Thanks to your lecture at the UCA convention, we recently began using code S9088 to group health insurance with great success. Can we bill that code on every visit?
A.If you meet the UCA definition of an urgent care center, then it seems appropriate to use the code for all visits. Exceptions might include:
- scheduled visits
- drug screen visits
- visits that do not involve the
Note: Some payors may refuse to pay on the code, and in the future some payors may ask you to reimburse them for the payments. If they do ask for reimbursement, you should see if they are allowed to do this by contract. At the very least, use this interaction as a starting point to educate the payor to the additional expenses and significant value of urgent care centers. Then work toward negotiating any parts of the contract that you don’t find optimal for your urgent care center.
Q.I just contracted with a major national managed care organization. I asked them if they recognized S9088. The provider representative stated they did not. She suggested that our urgent care use the code 99284 [level 4 emergency department (ED) evaluation and management (E/M) code]. The provider representative stated that all the urgent cares use this code frequently and that the payor would list this code as a “covered” code in our negotiated codes for reimbursement. Our urgent care physicians mentioned to me that this code (99284) is used for ERs only. Could you please shed some light on this issue?
A.It is correct that 99281-99285 are E/M codes for use in emergency departments. In general, these codes should not be used outside of a true emergency department. Making the issue even more confusing for coders, even in states that allow free-standing EDs, many payors are refusing to pay on ED E/M codes for freestanding emergency departments.
Be careful with accepting any unconventional information that you might receive from a provider representative, as the provider representative may be mistaken. As with the IRS, advice that you get on the phone is often incorrect. Even if the representative told you to code in that fashion, the payor might refuse to reimburse for emergency department E/M codes for services rendered in an urgent care center. Or, worse, a payor that does pay on the code might later require you to refund payments.
Using ED E/M codes in your urgent care, however, may be a compliant use of the code, if the payor specifically states that they will accept these ED codes from your place of service.
Before following this unconventional coding method, I would want the payor to confirm this policy in writing. If the payor does confirm that it will accept ED E/M codes, then you will want to clarify what place of service should be used, as many payors use edit software that will not accept ED E/M codes from POS-11 or POS-20.
Note: CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice
