DAVID STERN, MD (Practice Velocity)
Q.Payors do not seem to want to pay on the code E0572 (aerosol compressor, adjustable pressure, light duty for intermittent use). What can we do to get payment?
A.This code is not for simple use of the aerosol compressor, but is actually used to code for sale of the actual nebulizer machine. Thus, this code would rarely be appropriate for use in the urgent care setting.
Q.How do we get payors to reimburse for albuterol medications? They do not seem to pay on codes J7603 and J7609.
A.Medicare listings for the albuterol codes have been in a state of constant flux for the past few years. You should not use J7603 and J7609, as these have been removed from the Medicare fee schedule in 2008.
The appropriate codes are:
- J7611: concentrated albuterol (per 1 mg)
- J7612: concentrated levalbuterol (per 5 mg)
- J7613: unit dose albuterol (per 1 mg)
- J7614: unit dose levalbuterol (per 5 mg)
Use each code once for each milligram that is administered. For example, if you administer 2 mg of concentrated albuterol (usually diluted with saline), then you would code J7611x2.
Q.What is the proper coding for the administration of nebulizer treatment procedures?
A.Typical coding for nebulizer therapy for asthma in an urgent care setting would be:
- 94640: first nebulizer treatment
- 94640: each subsequent nebulizer treatment on each day
- A7003: administration set, with small volume non-filtered pneumatic nebulizer, disposable
- Use J7611, J7612, J7613, J7614 per the answer to the previous question.
Q.A national payor is clamping down on the 99051 code, claiming urgent care centers may not use this code because it is customary for urgent care centers to provide these hours of service and urgent care centers are already paid more than other physician practices (which is not necessarily the case). They also said that they are looking at whether these codes were paid in error in the past, and there’s talk about reclaiming those dollars. We recently received a letter from them requesting reimbursement back to 2006 for the claims where they paid us “in error” for 99051. So there is precedent for them going back and requesting reimbursement for claims paid in so-called “error.”
My question is, what error? And do they have a legitimate claim to require us to refund these clams?
A.The payor is mistaken that the code 99051 is only for hours outside of your “customary hours of service,” as the AMA defines this code as being for use during “regularly scheduled office hours.” Thus, this code should never be used for services rendered other than regularly scheduled clinic hours.
In fact, there is a specific code (99050) for services rendered “at times other than regularly scheduled office hours.” Thus, not only is that payor mistaken, but there is another code that is appropriate to the circumstances they describe. You were coding correctly.
As a general rule, payors can do what they want when reimbursing for these codes. As for take-backs, you may want to look at your contract to see if they have the right to do a take-back in this way. It sounds as though they have changed their rules for coding and are now trying to retroactively apply the new rules. You may need to con- tact a lawyer to see if you have a legal case to prevent the payor from applying new rules to old claims.
Usually, we try to use this type of a move by a payor as an opportunity to get a face-to-face meeting to explain:
- The benefits that the payor receives from after- hours care:
- Marketing to employers (i.e., we include quality urgent care providers).
- Making their most profitable members (i.e., the walking well that utilize very few healthcare re- sources) happy with their
- Reduced emergency department
- The additional costs that your urgent care incurs by providing after-hours care:
- Wages; we must pay more than typical primary care where hours are 9-5, Monday through Fri-
- Down time occurs when you are open—and paying staff—even when no patients come through the door, which can occur for hours at a When primary care practices have no scheduled visits, they can simply close up shop.
- Staffing to rush: Due to non-scheduled visits, an urgent care center needs to slightly overstaff so that unacceptable delays do not occur during un- expected rushes of
Then we tell the payor that there are many different ways for the payor to reimburse urgent care centers for these added expenses. Payors sometimes use S9088, 99051, problem-based coding (PBC), a fee schedule at about 120% of primary care fee schedule, or some other method.
The key issue is that we need a mutually beneficial way to continue the relationship. They want urgent care cen- ters to serve their clients, and urgent care centers need adequate reimbursement to pay the electric bill.
Note: CPT codes, descriptions, and other data only are copy- right 2007 American Medical Association. All Rights Re- served (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 appropri- ate legal advice.
