ED Coding and Reimbursement Alert

Question: We recently opened an urgent care clinic separate from the ED. Which E/M codes should we use to report the services at the clinic?

Codify Subscriber

Answer: To code and bill E/M services in the urgent care setting, you will use the Office or Other Outpatient E/M Level codes. The CPT^® code ranges for these E/M Levels are: 99201-99205 for new patients and 99211-99215 for established patients.

Zero in on These Key E/M Component Differences: Coders whose experience is mainly with the ED E/M levels 99281-99285 should carefully review the CPT^® guidelines for coding the Office and Other Outpatient Services levels, as there are some differences.

For example, for code 99204 (Office or other outpatient visit for a new patient…) the three key components required are a comprehensive history, comprehensive examination and MDM of moderate complexity, whereas the three key components for 99284 (Emergency department visit…) are a detailed history, a detailed examination and MDM of moderate complexity.

Another important coding difference you’ll need to know is that, while the ED visit levels require three key components to meet a certain level, the office and other outpatient visit levels for established patients require two of the three key components of history, examination and MDM.

Also note that typical times for the visits are listed in the individual code descriptions for the Office or Other Outpatient E/M codes, so counseling or coordination of care should be considered.

Don’t forget POS: Place of service for urgent care services can vary according to the payer guidelines and the specific characteristics of the urgent care center, so watch how you apply your POS indicator.

You will use place of service (POS) 11, 20, or 22:

• POS 20 is specifically for urgent care facilities defined by CPT^® as a location distinct from a hospital ED, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.  
• POS 22 is for an Outpatient Hospital; and 
• POS 11 is for an office location other than a hospital, SNF, military treatment facility, community health center, public health clinic or intermediate care facility where the health care professional provides routine health examinations, diagnosis and treatment of illness or injury on a routine basis.