Q. The patient in question is a new patient to the urgent care. At 10 a.m., she visited the urgent care with chief complaint of cough, headache, and myalgias. She was discharged home with a final diagnosis of cough and prescription for ibuprofen and cough syrup. At 3 p.m., she retuned with a complaint of headache and was treated with IM headache medications and sent home with a diagnosis of headache with pain meds.
How do we code such two visits by a new patient on the same day? I had coded the initial visit with a new patient level code and the subsequent visit on the same day as an established patient.
Radhika Sitaram, Bangalore, India
A. Only one E/M is allowed per day for any given patient. In your example, the documented history, physical exam, and complexity of medical decision-making for both visits should be combined; and the resulting new-patient E/M code (99201-99205) should be billed along with appropriate procedures and supplies. The two encounters are billed as a single encounter foe that date.
Q. Can CPT codes 99381 – 99397 (preventive visit, established, ages vary be code) be used for urgent care? If not, when are they applicable?
Question submitted by Eureka Haney, Southwest Medical Billing, San Jacinto, CA
A. This question is more a scope-of-practice question than a true coding question. Generally, urgent care centers may perform any services that may otherwise be performed in a physician office. In regard to these codes, they are typically used in a primary care setting, and some urgent care centers do offer primary care services.
The business of urgent care does not usually involve these comprehensive medicine evaluations and management services. If an urgent care center decides to perform such services, it is generally legal to do so. Unless an urgent care center is forbidden by state statute (and I am not aware of any such laws) or managed care contract from performing comprehensive medicine evaluations and management of from performing routine primary care medicine, then the urgent care center may perform these services.
When an urgent care center performs primary care services, it is important for both provider and patient to be clear on what obligations for follow-up, on-call services, and hospital admissions are to be provided. Providers should seek legal advice as to their obligations under federal and state statutes and rules.
For Medicaid preventive services, states operate under the federal Medicaid program Early and Periodic Screening, Diagnosis, and Treatment (EPSDT); each state may require specific (and/or unique) codes for billing under this program.
For non-Medicaid commercial insurers, the evaluation and management CPT codes for preventative medicine services are coded for the basic service (history, physical examination, and counseling/anticipatory guidance). Report separately CPT codes, as appropriate, for additional screening (hearing, vision, and development), laboratory services, and immunization administrations.
Q. We operate an urgent care center. On the UB-04, we are using place-of-service code 831, which I know is for an ambulatory surgery center (ASC). I have looked into it and feel that my provider should be using a 731 (Clinic/FQHC/Admit through discharge). Could this be the reason for our many denials that state we are not an ASC? Are we using the wrong POS?
Question submitted by Kayla Deaver
A. The UB-04 form has replaced the old UB-92 form. It is used for facilities that qualify to bill separate facility fees. This form does not use the same place-of-service (POS) codes as the CMS-1500 form. The code that you are describing is the type-of-bill (TOB) code, which is placed in Form Locator 4 in the top right-hand corner of the paper UB-04 form.
Yes, this TOB code is the likely source of your denials that state you are not an ASC. Code 831 is specifically for use in a “Special Facility or Hospital ASC/ASC for Outpatients/Admit Through Discharge.”
The term “special facility” is confusing. Most payors seem to ignore the “special facility” term, and apply this code only to ambulatory surgery centers. You are definitely not an ASC, so you should not use a code for ASCs.
Depending on your situation, you might use one of the following TOB codes on your UB-04:
- 131 Hospital/Outpatient/Admit Through Discharge
- 711 Clinic/Rural Health Clinic (RHC)/Admit Through Discharge
- 731 Clinic/FQHC/Admit Through Discharge
UB-04 billing is appropriate if your center is part of a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC). Hospital-owned urgent care centers should seek legal advice to determine whether the urgent care qualifies as a “hospital/outpatient” facility. If none of the above TOB codes apply to your facility, then it is likely that your urgent care center does not qualify to bill on the UB-04.
Many simple outpatient practice management systems cannot bill UB-04 claims. Thus, if you need to bill on a UB-04, then you need to select urgent care billing software that can bill UB-04 claims.
Note: CPT codes, descriptions, and other data only are copyright 2010, 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.
DAVID STERN, MD (Practice Velocity)
