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Confusion sometimes arises from urgent care facilities over which Place of Service (POS) code to use in billing.

Back in 2003 the Centers for Medicare and Medicaid Services created the “Urgent Care Facility” designation as POS-20, defined as “a location distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.”

The claims adjudication system is built around these identifiers (NPI, TIN, POS, etc), and they all affect reimbursement for urgent care centers, explains Kelly Mattingly, Director of Contracting and Credentialing at Practice Velocity.

There are several benefits for an urgent care to use POS -20. It establishes a track record of urgent care utilization in a particular market that justifies a higher payment scale for all urgent care centers. And, being recognized as an urgent care facility in contracting is useful when negotiating higher rates based on the extra costs of operating a walk-in facility.

Here are some points to consider when sorting through the issue of coding with POS-20 or POS-22, an outpatient hospital, or POS-11, a physician’s office.

CMS Guidelines

Most insurance plans follow CMS guidelines, so unless an insurance contract specifies that the urgent care facility should bill as POS-11 the center should use POS-20.

Contracts

If a provider uses the incorrect code based on what’s in their contract, claims may be denied, processed at an incorrect rate, or processed with an incorrect copay, said Monica Klosa, Director of PV Billing. If an urgent care center is set up in a payer’s system as a physician’s office, then claims using POS-20 may be rejected. It’s important to verify with each payer which POS code to use.

Reimbursement

If an urgent care center is affiliated with a physician’s office or multi-specialty group, it should consider whether reimbursement will be higher using POS-20 or POS-11. That depends on several factors:

  1. Does the urgent care bill with its own Tax ID# or that of the physician practice that owns the facility?
  2. Are insurance contracts negotiated separately for the urgent care or as a package for the entire practice?
  3. Do providers who are seeing urgent care patients also practice in the physician office or multi-specialty group that owns the facility?
  4. Is a different co-pay charged because patients are being seen as a specialist or urgent care facility (as opposed to a regular office visit)?

Conclusion

While there are benefits to using the POS-20 code instead of POS-11, there are important steps to consider before simply changing the billing number.  The most important consideration is to verify that the code you use aligns with the type of service provided by your clinic and what is designated in the contracts. “Otherwise claims will not pay appropriately,” Mattingly said. Work closely with your payers and verify contracts to make sure you don’t pay the price down the road.

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