Question Urgent Care E&M Levels

alumnieib

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We are really having confusion with Urgent Care Billing. We have adopted guidelines that indicate when setting the level, the MDM is ALWAYS one of two components. And it was stated that when RX mgmt is performed it is always a level 4.

My question is, are ALL visits in the UC scored as a New Problem to the Examiner? For example, now all my docs are giving level 4s to Common Colds. I would still say this is a self limiting problem and is a level 3, even with rx Mgmt.

Please help! If you know of any links to CMS or other reputable source that addresses this.

Thank you
 

thomas7331

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We had this same issue in the urgent care clinic at the facility where I used to work. An external audit firm reviewed many of our records and advised us that almost all payers follow an unwritten rule that a visit for single problem with a prescription and no other complications, diagnostic tests, comorbidities, or other complicating factors should not be coded higher than a level 3. I think this rule of thumb works well to prevent up-coding that doesn't meet medical necessity, such as in the case of a common cold as you describe, and I think most auditors also agree based on the factor that writing a prescription alone is not the same as complex prescription drug management, and therefore does not automatically qualify for moderate risk . Unfortunately, there isn't a lot of official guidance on this, so your practice of facility will probably have to make an internal decision as to what is best. One reference I can point you to that does support this is Appendix C, Clinical Examples, from the CPT book, which gives some guidance on the E&M levels that are typical for a variety of types of patients in many different specialties.
 

alumnieib

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Thank you so much. This is my thinking also. I know there isn't a lot of guidance so it really has been a struggle to get something as policy. I will look at those examples in the Appendix C and see if there may be something suitable.
 
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