Practice Management
Q: What is case-rate reimbursement, and how does it work in the urgent care sector? A: Case rate, sometimes called flat rate, describes a reimbursement structure in which providers receive a flat reimbursement rate for every patient visit, no matter what service they provide. Case-rate reimbursement means that the urgent care is contracted with the payor to receive the same reimbursement regardless of the acuity of care, whether it’s the treatment of a hangnail or …
Read MoreQ: Do you have information on the 2017-2018 influenza vaccine codes? A: The American Medical Association (AMA) recently published a list of new and revised vaccine codes on their website (https://www.ama-assn.org/sites/default/files/media-browser/public/cpt/vaccine-long-desc-july-2017.pdf). These codes will be published in the 2018 Current Procedural Terminology (CPT) manual. The two new influenza vaccines on the list are: 90682, “Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use” 90756, …
Read MoreQ: What can we bill for when we give a patient a nebulizer treatment for an acute airway obstruction during an exacerbation of asthma, or wheezing due to an upper respiratory ailment? A: You can bill for the service and the medication. However, depending on the payer rules, the medication might be bundled into the service. Time is a factor when billing the service. If the treatment is less than 1 hour, you would bill …
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It’s again time to review what has changed with the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) effective October 1, 2017 through September 30, 2018. There are 360 new, 142 deleted, and 226 revised diagnosis codes in the final update. We will review the changes most relevant to urgent care, but the examples shown here are not all-inclusive. You can find all updates in the Centers for Medicare and Medicaid Services (CMS) website …
Read MoreQ: What is the difference between a detailed exam and an expanded problem-focused exam? A: Unfortunately, there is no straightforward answer to that question. The Centers for Medicare and Medicaid Services (CMS) provides some guidance in the 1995 and 1997 guidelines (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243514.html). The 1995 guidelines state the documentation of the examination as follows: Problem-Focused – A limited examination of the affected body area or organ system. Expanded Problem-Focused –A limited examination of the affected body …
Read MoreQ: We had a patient present with multiple lacerations and were wondering how to bill, since some were repaired with sutures and some were repaired with staples. A: Laceration repair is billed based on the complexity, length of the repair, and the anatomic site. The repair can consist of sutures, staples, or wound adhesive (eg, Dermabond). The Current Procedural Terminology (CPT) manual classifies the complexity of the repair of wounds as being simple, intermediate, or …
Read MoreQ: We are planning to open a new clinic that will offer both primary care and urgent care services. Can we use the same tax identification number (TIN) when we start negotiating contracts with insurance payors? A: Based on our experience with doing this many times, if you attempt to use the same TIN for both primary care (PC) and urgent care (UC), you are likely to see the following results: Some payors are likely …
Read MoreQ: Can we bill for critical care services when spending extra time with patients who are very ill? A: It is rare that you would perform billable critical care services in the urgent care setting. According to the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA), critical care is defined as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical …
Read MoreQ: We are coding for an urgent care group that is owned by a hospital and bills on a CMS-1500 for professional services and the UB-04 for facility services. We bill using Place of Service (POS) code 22. Is this correct? A: Prior to January 1, 2016, the Centers for Medicare and Medicaid Services (CMS) POS code set did not differentiate between an urgent care operating on campus or off campus. As of January 1, …
Read MoreQ: Can you bill for splint and cast applications done by someone on staff other than the physician? A: Yes, you can still bill for the service if the application is performed by someone else in the clinic. The American Medical Association (AMA) provided guidance on this in the Current Procedural Terminology (CPT) Assistant, April 2002 issue: “You will note that the reference to ‘physician’ has been retained in the clinical examples provided. This inclusion …
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