ED Coding and Reimbursement Alert

To become more attractive to managed care payersand to compete with private clinicsmany hospitals are opening urgent care centers, (UCCs) in or near their facilities. Conceived as a sort of hybrid between an emergency department and a primary care clinic, these centers are designed to serve walk-in non-emergency patients without an appointment.

In many cases, these UCCs are located either within or next to the hospitals regular emergency department, and are staffed with emergency physicians, nurses, and other emergency providers, notes David McKenzie, director of reimbursement for the American College of Emergency Physicians (ACEP) in Irving, TX.

This development has presented several dilemmas for emergency medicine billers and coders as they try to determine how to correctly bill for services and supplies provided by emergency physicians in these urgent care centers.

Use Outpatient E/M Codes in UCCs

At some facilities, the urgent care center is open between certain hours (say 10 a.m. and 10 p.m.), but that space functions as part of the ED at other times.

This obviously creates a lot of confusion for the billing staff, who find it difficult to bill emergency department E/M codes and outpatient E/M codes for the same physicians, sometimes performing the same procedures, in, essentially, the same facility but during different times of the day.

Any tips for charging ER codes vs. outpatient office codes in an urgent care center? writes Charles Runels, MD, a staff emergency physician at Thomas Hospital in Fairhope, AL. We have a hospital-owned urgent care center that is staffed by our EDs group of physicians. Our administrators are telling us that we must bill a smaller charge for the same services when they are provided at the urgent care center.

For the hospital to be competitive, it must offer managed care plans an affordable alternative to the emergency department for minor, episodic, unscheduled medical care, explains McKenzie.

Because emergency departments have to be prepared to handle serious emergencies of all different types and must be open 24 hours a day, the E/M codes and other codes for treatment in the ED have significantly higher relative value units than outpatient or physician office codes.

Urgent care centers are supposed to draw patients with minor bumps, bruises and colds away from the expensive ED. The UCC is only open certain hours and usually equipped to handle just a set level of medical care, McKenzie notes.

Physician services in urgent care centers should be billed with CPT 99201 - 99205 (office or other outpatient visit for the evaluation and management of a new patient).

To correctly bill for a service using the emergency department services codes (99281-99285), the service must be provided in a hospital-based facility that is open 24 hours a day specifically for the provision of unscheduled, episodic care, he explains. You can bill outpatient/office codes in the ED, but you cant use ED codes in an office or clinic.

In reality, however, urgent care centers often end up becoming de facto emergency departments, but operating without the same financial and operational support.
In Runels case, his hospital opened the urgent care center at a separate site, five miles away from the main campus. Since the center opened, he has delivered a premature infant who had to be airlifted by helicopter to the hospital, and intubated an elderly woman who presented at the clinics door with difficulty breathing after suffering multiple seizures.

It turns out that we see the same things here that we see in the emergency room. We dont have ambulances showing up, but we have people coming in with MIs, and with seizures. People in the community just drive up.

The result is, he and other physicians are being paid significantly less for providing the same medical care, just in a site other than the ED.

That is a typical problem, agrees Andrea Clark, RRA, CCS, CPCH, a senior health care consultant with the American Health Information Management Association in Baltimore, MD.

People with a medical problem are not going to differentiate between the definition of an emergency department and an urgent care center, she says. They are just going to go to whichever is closer.

She agrees that physicians in urgent care centers cannot use the emergency department service codes.

What many hospitals have done, she contends, is place the urgent care center next door to the emergency department.

Basically, as the patient steps in the door they will be triaged, minor cases go to urgent care, serious ones to the emergency department side, Clark says.

This eliminates some of the undercharging, but really does nothing to help Runels case, she acknowledges.

In reality, even urgent care centers should be using only the first three outpatient E/M codes because anything higher (for episodic care) should be an ED visit, she adds.

Note: Billing for the facility side of urgent care services also presents many challenges. Issues like billing for patients who are later admitted to the hospital, but were treated at an off-site urgent care center, and billing for supplies used in a stand-alone UCC will be covered in a future issue of EDCA.