ED Coding and Reimbursement Alert

In the January issue of ED Coding Alert, we covered the issue of coding for E/M services delivered by ED physicians in a hospital-owned, off-site urgent care center.

We received several comments from readers questioning use of the office/outpatient codes for a new patient (99201-99205) for E/M services delivered in that setting.

“When centers are within the hospital, staffed with the same ratio of physicians and practice extenders, and open 24 hours; there is no rationale for the physicians to code differently (i.e., not use the emergency service E/M codes [99281-99285],” writes Phyllis Whitney, director of Apollo Information Services, Inc., which bills for emergency physician groups in Fort Myers, FL.

Indeed, it is not always appropriate to code for E/M services delivered in an urgent care center with office/ outpatient E/M codes. The codes used are based on whether the patient is registered in the ED, where the center is located, and, most importantly, how the hospital bills the place of service on the UB92 facility claim form, says Caral Edelberg, CPC, president of Medical Management Resources, Inc., a Jacksonville, FL-based emergency medicine coding company and consulting firm.

Center/Fast Track is in the Main ED

In many hospitals, patients may be registered in the ED, triaged by the ED nurse, but, seen by an emergency physician in the ED’s urgent care center or “fast track” area of the ED.

Normally, these centers are designed to see lowacuity patients (usually a level 1 level 2, or level 3 visit) only and, therefore, these patients are treated quickly for their minor injuries without waiting behind the higher acuity, more severely ill or injured, patients.

“If the patient is registered in the ED, and the hospital bills for the services delivered in the urgent care center or fast track with the place of service as ‘23,’ the number for the ED place of service, then the emergency service codes should definitely be used,” Edelberg advises.

Note: If the patient is registered in the ED and sent to the fast track, and the hospital is not reporting the place of service with ‘23,’ then ED administrators should find out why. The group will encounter problems if they bill emergency service codes in an area other than the ED. Furthermore, if the patient is registered in the ED, the personnel are under COBRA regulations to provide a screening exam no matter what the patient acuity—so the emergency codes are the most appropriate.

Center is Off-Site and Billed as a Clinic

In some cases, as in the previous article, hospitalowned urgent care centers (also called Express Care, STAT Care, etc.) are located in a separate area of the hospital or away from the hospital altogether.

In that case, Edelberg advises, she would check to see how the hospital is billing its facility charges for that center.

On the UB92 claim form, under place of service, there are numbers that correspond to the sites of service, she explains. The number 11 indicates that the visit occurred in a physician’s office or a clinic, 22 is the hospital code, and 23 is the ED site-of-service code.

If the hospital is billing facility charges as a clinic or hospital site of service, then the physicians should bill report the office/outpatient E/M codes (99201-99205-new patient, 99211-99215, established patient).

“If the hospital that owns the center is billing it as a clinic and you are using emergency service codes, third-party payers may have a problem with that,” she states.

Some hospitals (and some emergency physician groups) own free-standing “emergency departments” that are separate from the hospital.

“They may be officially designated emergency departments and not urgent care centers or free-standing primary care clinics,” states Edelberg.

In that case, as long as the hospital or group is correctly billing the place of service with the number 23—to indicate an ED site of service—the physicians can use the emergency service E/M codes.

Using New or Established E/M Codes?

The tricky area with using the office/outpatient codes is the transient nature of urgent care services. In the ED, there are no new or established patients.

Therefore, the emergency E/M codes reflect this by indicating that these codes are the same whether the patient has or has not been seen before in that ED.

Urgent care centers and fast track areas are, obviously, seeing the same kinds of patients, they are just seeing those with minor injuries.

However, many of these centers use the office/outpatient E/M codes, which differentiate between new patients and established patients. The new patient codes carry higher relative value units (RVUs) and, therefore, higher reimbursement. (See chart comparing the RVUs for emergency E/M codes to new and established office/ outpatient codes on this page.)

However, patients seen more than once by the same physician, or another physician employed by the same practice, within three years’ time are deemed to be established patients, by HCFA rules.

This presents a problem in urgent care centers and clinics because, of course, there are no “regular” patients or scheduled visits, patients come in off the street.

“Because of the size of our client base, we don’t keep zero balance accounts on our system for three years,” continues Whitney, regarding visits to the group’s off-site clinic. “There is no practical way to know whether the patient has been seen at another site our client staffs and, therefore, fails the criteria for the new patient category.”Whitney is caught in a seeming Catch-22, if she bills all urgent care visits as new patients (99201-99205), then she risks a Medicare fine or third-party payer demand for repayment if a patient has actually been seen previously by a physician in that group within three years’ time.

“Rather than risk loss at an audit, we decided to bill all visits as established patients (99211-99215) ,” she explains.

However, the RVUs for these codes are lower than the codes for new patients.“That is a significant amount of money that they are leaving on the table for new patients,” Edelberg indicates.

The amount of added reimbursement would probably be worth finding a way to keep track of the patients for three years, she feels.

Negotiating with Third-Party Payers

In deciding how to bill for E/M services in urgent care centers and fast-track areas within the ED, it may also be beneficial to examine the emergency group’s contracts with third-party payers.

The new-patient, office/outpatient level 1 and level 2 E/M codes actually carry higher RVUs than the low-level emergency service E/M codes. (See chart.)

“Some third-party payers may allow you to charge the office/ outpatient charges in the ED, if certain criteria are met,” she states.

For example, some third-party payers allow ED physicians to bill low-level fast-track visits with the office/outpatient codes instead of low-level emergency service E/M codes if the patient is seen with in a specified amount of time (e.g., within 15 minutes). This is designed to encourage the physicians to get that payer’s patients in and out of the ED without a long wait, Edelberg explains.

Because coding in this manner involves changing the codes for specific payers, it means more work for the ED professional coders. But, it could yield significant added reimbursement, Edelberg points out.