Handling Medicare and S Codes in Urgent Care 

Q: How do we bill the urgent care codes S9083 vs. S9088? Can we bill E/M codes with the S codes?

A: HCPCS Code S9088, “Services provided in an urgent care center (list in addition to code for service)” can be billed for every visit in an urgent care center with an E/M code, with the exception of Medicare. This code is an add-on code, so it cannot be billed alone. You would bill E/M codes 99201-99215 as appropriate, along with any procedure codes if procedures were performed during the visit.

Some payors recognize that services rendered in an urgent care center cost significantly more than the services that are rendered in traditional primary care physician offices. This add-on code was designed to allow urgent care centers to be reimbursed for at least a portion of this increased cost of rendering service. You will want to check your contracts with other payors since this code might be bundled per your agreement with them.

HCPCS code S9083, “Global fee urgent care centers” is used in place of the E/M code, and (depending on the specific payor contract) often it is the only code billed, even when other services have been performed. This code is typically only used when it is required by a payor that you have an agreement with and is often referred to as a “case rate.” This code is used by payors to bundle all services rendered in an urgent care visit, regardless of the complexity of the procedure.

Case rate coding is a good option for clinics that are prepared to care only for minor illnesses and injuries such as colds, insect bites, and minor bruises. However, if your urgent care is equipped to take care of many moderate-acuity injuries and illnesses (e.g., dehydration requiring intravenous fluids, fractures, complicated lacerations, corneal rust rings, and others), the S9083 reimbursement option is far from ideal. If an urgent care is always reimbursed the same flat rate per patient, regardless of the actual cost of treating the patient, the urgent care can only see patients with minor illnesses and injuries in order to stay afloat financially.

Q: How do you code for an urgent care visit and bill the urgent care portion to Medicare? Do you know how I can find Medicare reimbursement rates? If a Medicare patient is seen at an urgent care center, how do I bill for the physician portion and the facility portion separately? Would I use E/M codes or can we only bill the S codes assigned for urgent care? I heard that Medicare does not pay for S codes.

A: Urgent care billing and coding is quite unique.  However, for Medicare, there are no special rules for urgent care, as Medicare does not recognize urgent care as separate from any other outpatient physician office.  If the patient is treated at an urgent care center, you bill E/M codes 99201-99215 as appropriate from the Office or Other Outpatient Services section of the CPT manual. You would also code (adding modifiers as appropriate) for any procedures performed during the visit.

S codes are never billed to Medicare.  They have been requested by and are used exclusively by private sector payors.

To review reimbursement rates from Medicare, you will access their website for the physician fee look up tool at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html, which provides help on how to navigate the site. There is also a link on this page that will provide you with even more information on how to use the search site at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How_to_MPFS_Booklet_ICN901344.pdf as well as the link for the fee schedule itself http://www.cms.gov/apps/physician-fee-schedule/overview.aspx.

**Added from a different article but pertains to S9088/99051**

Q:  Can we bill both the S9088 and 99051 on same visit for our urgent care visits?

Yes, you can bill both codes for the same visit along with the E/M code. HCPCS code S9088, “Services provided in an urgent care center (list in addition to code for service)” is specifically for use in an urgent care center. You would bill this code for every visit. Keep in mind that Medicare does not recognize this code at all so you would bill it to all payors except Medicare.

CPT code 99051, “Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service” is another code that could be billed to insurances, with the exception of Medicare. 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. This code is typically billed to patients seen after 5 p.m. Monday through Friday and all day on Saturday, Sunday, and federal holidays.

Check the policies of each of your payors for both of these codes to see if you can receive compensation from them. Try to include reimbursement fees for these codes as well when negotiating contracts.