Wiki Correct way to bill Urgent Care visit in Freestanding UC that is part of Hospital System?

annettbg

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A free standing Urgent Care under the umbrella of a Hospital system is billing Rev code 456 with 99283. Some insurers are processing this with an ER copay vs. Urgent Care copay. The CPT book notes for codes 99281-99285 the facility must be available 24 hours/day. In this case the Urgent Care facility has limited hours. Also since Rev Code 456 is under the ER section of the Revenue codes they are noting it should have ER copay applied.
Are there different guidelines for billing Urgent Care that is owned by a hopsital system? It seems like more appropriate billing in this scenario would be 0526 for Freenstanding Urgent Care Clinic or 0516 for Urgent Care Clinic since it is Hospital owned. What CPT code should be used for the E/M in this case? Thanks,
 
This is totally NOT my area. However, isn't 456 for urgent care in an emergency room? Not for urgent care in an urgent care center? Look in the 500 series.
 
Sharon,
That is exactly what I thought also since it is in the ER section. But I've been told that since it says Urgent Care it should have UC copay apply. So I was confused and thought that maybe since the facility is owned by a hospital system the rules were different. But adding the 99283 if they consider it Urgent Care doens't make sense to me.
 
Again, not my area (I cannot stress that enough), but if you look at the list of revenue codes, you'll see that the first item is the location (for the most part), and the second item is the type of care. For instance:

540, Ambulance, general
546, Ambulance, neonatal services

So if you were providing neonatal services NOT in an ambulance, you would not use 546.

When we look at the 450 series, we see this:
450, Emergency room, general
451, Emergency room, EMTALA emergency medical screening
456, Emergency room, urgent care

So if you were doing an EMTALA emergency medical screening NOT in an ER, you would not use 451. In the same way, doing urgent care NOT in an ER, you would not use 456.

516, Clinic, urgent care
526 Urgent care clinic

I admit I do NOT know the difference between these two. I have a feeling that 516 is a general clinic where the patient happens to be getting urgent care, and 526 is an actual Urgent Care Clinic (your situation).
 
To start with, I would not bill the 99281-99285 codes for an urgent care visit - I think that is incorrect and that is more likely what is causing the problem. I think the revenue code question is less important.

You may need to check with your individual payers and contracts for guidance on this. The urgent care center under the hospital where I used to work had to bill differently for different payers. It was a while ago, but as I remember, the CMS payers allowed the revenue code 0456 but required the G0463 HCPCS on the facility side, with 99201-99215 for the professional, the same as if it was a clinic visit. Some commercial payers stipulated that HCPCS S9088 be billed on the facility claim, while others required the entire amount be billed on a professional claim as if it was an office service. But I think there's more involved here than just what revenue code you choose as payers have different requirements for this type of situation.
 
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