ED Coding and Reimbursement Alert

The documentation guidelines are different for this non- ED site of service. Do you know how to use them?

If your ED practice has expanded its reach to include urgent care staffing or urgent care center (UCC) ownership, you’ll have to upgrade your documentation guidelines mastery for these settings if you’re looking for deserved pay. 

Refresher: UCCs are generally equipped to treat non-life-threatening acute injuries and illnesses that do not require hospital admission. Most UCCs also provide other non-emergent services such as prescription refills, sports/school physicals, occupational health services, vaccinations and STD testing says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Zotec Partners in Durham, NC. 

Use Office E/M Codes For Services Outside the ED 

To code and bill Evaluation and Management Levels 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. 

CPT® defines a new patient as a patient “who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years,” says Norris. 

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, warns Norris. 

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 3 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, Norris says. 

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, Norris adds. 

Don’t Forget The POS Code Is Different, Too

Place of service for urgent care services can vary according to the payer guidelines and the specific characteristics of the UCC, 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, Norris explains.