E/M Distribution for Urgent Care

hsmith67

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CMS has what they expect, what OIG expects for E&M code distribution in an office/outpatient primary care setting. Does anyone know where I could find the same data specifically for Urgent Care facilities? Someone is telling me "we should have 85% of our new patient visits be 99204" and that does not make any sense to me at all. Urgent care is for a specific problem and I do not see how 85% of these patients would require/justify a comprehensive history a comprehensive physical exam and a moderate complexity MDM. Does anyone have any source on this information to settle this dispute?

Thanks,
Hunter Smith, CPC
 

Pathos

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I see the statement you are presenting only too many times regarding having E/M level standards. I can understand from a Practice Manager point of view, how they want to maximize reimbursement in an already stressed economy, however the backlash can be severe. If you ask any auditor, they will tell you that any chart note should support medical necessity of any E/M level. Even with the Marshfield Clinic tool (the one with all the points), you cannot fully reach medical necessity, albeit close at times.

I have been told by certain managers at previous jobs that most Express/Quick/Power Care visits (non-Urgent but powered mostly by NPs) should be 99214s, and tailor the providers' template to hit those levels for History and MDM (1 new problem and 1 Rx). This is a very dangerous practice unless audits can genuinely find medical necessity in the chart. E/M level inflation is part of the reason CMS is doing a revamp of the way they will pay for E/M visits come 2021, where documentation requirements only have to meet 99202/99212 and perhaps 99205/99215 depending on possible final changes.

I have other opinions about this E/M change, but nothing that is relevant in this thread. Instead, I will just caution again against any required E/M level for any clinic, especially at an Urgent Care clinic. Most CMS and MAC guidelines will explain that any E/M level will need to stand against medical necessity.

Hope this is useful!
 

hsmith67

Guru
Messages
100
Location
Greenville, NC
Best answers
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I see the statement you are presenting only too many times regarding having E/M level standards. I can understand from a Practice Manager point of view, how they want to maximize reimbursement in an already stressed economy, however the backlash can be severe. If you ask any auditor, they will tell you that any chart note should support medical necessity of any E/M level. Even with the Marshfield Clinic tool (the one with all the points), you cannot fully reach medical necessity, albeit close at times.

I have been told by certain managers at previous jobs that most Express/Quick/Power Care visits (non-Urgent but powered mostly by NPs) should be 99214s, and tailor the providers' template to hit those levels for History and MDM (1 new problem and 1 Rx). This is a very dangerous practice unless audits can genuinely find medical necessity in the chart. E/M level inflation is part of the reason CMS is doing a revamp of the way they will pay for E/M visits come 2021, where documentation requirements only have to meet 99202/99212 and perhaps 99205/99215 depending on possible final changes.

I have other opinions about this E/M change, but nothing that is relevant in this thread. Instead, I will just caution again against any required E/M level for any clinic, especially at an Urgent Care clinic. Most CMS and MAC guidelines will explain that any E/M level will need to stand against medical necessity.

Hope this is useful!
Pathos,

Thanks for the reply. I agree with everything you said and am confident most if not all CPC's agree. The difference of opinion is between me and a non-biller/non-coder/executive that simply can't let go of 85% of new urgent care visits should be 99204's. I really need a "reputable source" like CMS, MGMA, AAPC, etc. that can give me an industry standard or industry norm like we can find for primary outpatient visits. Anyone out there have any sources vs. our own "common sense opinion?

Thanks,
Hunter Smith, CPC
 
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