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urgent care

  1. #1
    Default urgent care
    Medical Coding Books
    Good afternoon Coding world,

    Can a facility say they are urgent care, and less expensive by charging the patient urgent care co pay but bill your insurance emergency room fees?

    The insurance company did not pay, but there was a contractual adjustment made. now the statement for the balance was sent to the patient.

  2. #2
    Quote Originally Posted by coder1 View Post
    Good afternoon Coding world,

    Can a facility say they are urgent care, and less expensive by charging the patient urgent care co pay but bill your insurance emergency room fees?

    The insurance company did not pay, but there was a contractual adjustment made. now the statement for the balance was sent to the patient.
    To bill an insurance ER fees, it has to be a designated ER facility. Urgent care typically follows the same type of rules, but they're different from ER. We have several clinic locations that plainly say "Urgent Care" on the sign, but they're not technically Urgent Care facilities, in the sense that we would billl insurers using an Urgent Care POS code. (They're treated like regular clinics, with POS 11). You should billl the insurer and the patient according to how your facility is licensed to bill. If it's an ER, then bill an ER copay. If it's Urgent Care, billl the correct place of service to the insurer. I wouldn't advise mixing and matching unless you're particularly fond of fraud investigations.

    Secondly - whether this was Urgent or ER, chances are, the insurer should have paid something on it. Even the worst plans in existence usually offer some type of Urgent/Emergency coverage - often times, even if the provider is out of network. I would definitely do some more investigating to see if the claim was billed correctly, processed correctly, and/or if it can be appealed. Hope that helps!

  3. #3

    This is personal, I was charged as urgent care co pay but was told by the urgent care that they bill insurance as emergency. They practice that they are less expensive then a emergency visit. But the physician portion came from a billing company which charge me for a level 4 emergency visit with a trigger point procedure.

    The billing company told me that my insurance made a payment. but once I viewed the itemized bill, I notice there wasn't a payment but a contractual adjustment.

  4. #4
    Did you call your insurer to find out what they received a claim for, and how they processed it? I wouldn't take the billing company's word as absolute - I can tell you firsthand that there are a lot of people out there that wouldn't know if they were misinformed, and would pass that bad info on to a patient. Sometimes you've got to do the legwork yourself, unfortunately.

  5. #5
    I've tried to look up online for the EOB... no success. I will call them when I get off work.

  6. Default FP coding UC visits
    I work in a family practice setting, hours of operations are 8:30am-5pm Monday -Friday. My employer and I had almost an heated discussion where I was told to use
    urgent care visit code when a patient comes in without a scheduled appointment. My concerns with this are, we are not urgent care facitlity, we are PCP and have signs posted "walkins are welcome", as far as I know non of our contracts with payors stipulates they will pay for urgent care codes. I am now under a lot of pressure to code as such but refuse to until I am better educated on this. I asked my employee what constitute as "emergency" I was told that "any unscheduled appointment is an urgent code visit, you can call on the same day and its urgent, you need to be seen right away it is urgent". I do not agree, please help. Thanks
    Last edited by Sadams51; 01-31-2013 at 09:38 AM.

  7. Default

    I am not certain as to what "urgent care visit code" your employer is referring to.

    but, what I believe what your employer may be referring to is the 99051, "services rendered during extended hours". This is an add on code, that would NOT replace any other code. Many payors do not even reimburse for it, but some are beginning to. So, its worth a shot. The place of service does NOT have to be an Urgent Care. It can be a family practice, from what I understand.

    I found this online, it helps to better understand the purpose of this code:

    "CPT code 99051 can be used when you provide services "during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service." Evening hours are generally considered to start at 5 p.m. This code was designed to compensate your practice for the additional costs of being open extended hours. Not all payors will reimburse you for this code, but many payors recognize the value and cost of these services and will reimburse for this code. Check the policies of each of your payors to see if you can receive compensation from them. There is no need to check Medicare's policy, though: Medicare will never reimburse for this code, so never use it with them."

    Kelly Wadle, CPC

  8. #8
    UT Dallas, TX Chapter
    Default Urgent Care vs ER
    Addressing the first question on charging patients an urgent care copay but possibly billing an ER visit, I would call the insurance company and talk with a rep and ask how the claim was billed. Primarily we need to know what place of service was billed since that determines how the benefits are applied. If they billed place of service 20 or 22 then your urgent care copay should have applied correctly, but if they billed a 23 then the ER copay/deductible-coins should apply and you would know then that it was billed incorrectly as you were not told that they were going to bill this way. Then you could contact the billing agency and ask them why they submitted a claim to the insurance company with the incorrect place of service.

    For the second question on patients with no appointments to bill as urgent care - This is what I found regarding that.

    CPT Assistant August 2010 addresses After Hours Office Services (Codes 99050-99051)

    Let the Clock Determine 99050 vs. 99051 (AMA source)

    If your physician sees a patient in the office during hours when the practice would normally be closed, such as on weekends or after 6 p.m., CPT guidelines allow you to bill 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed [e.g., holidays, Saturday or Sunday], in addition to basic service) as long as the documentation supports the afterhours service, says Jetton Torix, CCS-P, CPC-H, course director of Knowledge Source Seminars in Star, Idaho.

    Keep in mind: A patient is considered an after-hours patient only if he reports to the office after your normal office hour's end — not when he presents during normal office hours and the appointment runs past closing time.

    When your physician provides an E/M service in the office during regularly scheduled “evening, weekend, or holiday office hours,” by contrast, you should bill 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service), according to AMA guidelines outlined in the CPT Assistant (Vol. 13, Issue 6, June 2003).

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