Q. The coding staff has relayed to me that we can now bill for times when my clinical staff must spend extra time with a patient. Is this true? What are the requirements for documentation? A. Yes, two new Current Procedural Terminology (CPT) codes added in 2016 by the American Medical Association allow you to bill for clinical staff members’ time spent with a patient above and beyond what is considered to be the usual amount of time. …
Read MoreProtecting Your Urgent Care Center Against Whistle-Blowers
Urgent message: Government financial enticements for whistleblowing have resulted in a sharp rise in employee reports against their health-care employers. Urgent care centers can protect themselves by identifying potentially litigious employees, having a wellpublicized compliance program, and by establishing internal reporting procedures. Introduction In recent years, there has been a dramatic rise in the number of whistle-blower lawsuits in the health-care industry. Because these lawsuits reap huge payouts for the federal government, whistle-blowers are monetarily enticed to report their employers to government agencies rather …
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Roundtable: Expert Perspectives on X-Ray Over- Read Strategies in Urgent Care
Urgent message: To ensure a high quality of patient care and reduce the risk of medical errors while also controlling administrative overhead, every urgent care center should have a clear policy and process for radiologist interpretation of x-ray images, image over-read, or both. IntroductionAs health-care costs continue to multiply, it is important to consider money-saving measures across the board. Radiography is an essential service in differentiating urgent care centers from primary care and other providers, …
Read MoreTop 20 Medications Prescribed
Data from the 2014 Urgent Care Chart Survey of 150 million visits by patients to more than 800 different urgent care clinics, conducted by the Journal of Urgent Care Medicine, reveal that the top three most-prescribed medications at U.S. urgent care centers were, in descending order: Zithromax (azithromycin), for 12.12% of visits Amoxil (amoxicillin), for 8.25% of visits Deltasone (prednisone), for 7.07% of visits The top 20 medications are shown here. We will report on …
Read MoreExcludes Notations and Code Notes
Q. How do I use Excludes 1 and Excludes 2 instructions in International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10CM)? A. Put simply, the Excludes 1 notation means that you cannot code any excluded code with the main (listed) code. Conditions listed with Excludes 1 are mutually exclusive. For example, code E11 (type 2 diabetes mellitus) has an Excludes 1 notation with the following codes listed: Diabetes mellitus due to underlying condition (E08.-) Drug …
Read MoreTurning Over Patient Records on Request
Urgent message: Urgent care providers subject to the privacy regulations of the Health Insurance Portability and Accountability Act of 1996 need compliant procedures for handling patient requests for medical records, including transfer of patient records to other providers. U.S. federal and state laws require providers to allow patients access to their medical records. This includes records supplied by another provider (e.g., a specialist who has forwarded a report to the primary-care physician) that may be …
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We’re All in This Together: Four Attributes of Effective Medical Center Teams
Urgent message: Creating and cultivating cohesive, goal-oriented, and patient-focused urgent care teams starts with visible front-line leaders who emphasize a strong service culture, open communication, personal accountability, and management transparency. ALAN A. AYERS, MBA, MAcc Practice Velocity Introduction The stress, resentment, and dissatisfaction that one experiences being part of a disconnected and ineffective team are not easily forgotten. Common sense may lead one to believe that the safest path is to ignore the team’s dysfunction and consider it just a part of …
Read MoreDIAGNOSIS CODES DETAIL
Data from the 2014 Urgent Care Chart Survey of 1,778,075 blinded visits by patients to more than 800 different urgent care clinics, conducted by the Journal of Urgent Care Medicine, reveal that for 2014, the top three diagnosis codes at U.S. urgent care centers involved, in descending order: Wounds,15.9% Sinusitis, 11.4% Respiratory conditions, other, 11.2% The bottom three diagnosis codes involved, in descending order: Influenza, 1.6% Tonsillitis, 1.5% Gynecologic issues, 1.5% The survey’s methodology and …
Read More2016 Current Procedural Terminology Changes Pertinent to Urgent Care
Evaluation and Management There were two revisions and two additions to the “Evaluation and Management” section. Add-on codes 99354, “Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour,” and 99355, “. . . each additional 30 minutes,” were revised to add the term psychotherapy in the description. Some good news in …
Read MoreComplying with Medical Information Restrictions of the Family Medical Leave Act and Americans with Disabilities Act
Urgent message: Urgent care centers that are subject to the Family Medical Leave Act and the Americans with Disabilities Act are limited on the types of questions they can ask related to employee requests for leave. To avoid legal problems, managers should understand the requirements for leave and implement a process for handling information requests. Spencer Hamer, JD Two common laws that employers must deal with regarding employee leave requests are the Family Medical Leave Act (FMLA) and the Americans with Disabilities …
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