This page is expanded from a column by David Stern, MD, CPC in the Journal of Urgent Care Medicine, December 2006
What is HCPCS code S9088?
Many payors recognize that the actual cost of otherwise seemingly identical services will generally be significantly higher when rendered in an urgent care center, compared with the cost of rendering the same services in traditional primary care physician offices. The reasons for this increased cost include:
- Unscheduled appointments mean that patient flow in the urgent care center is quite unpredictable, so the urgent care center will sometimes be open for hours, serving no patients and generating no income. Meanwhile, the expenses of salaries, benefits, heating/cooling, etc. will continue to accrue.
- Staff in primary care physician offices generally work bankers hours. Staff in urgent care centers work weekends, holidays and evenings. Thus, hourly compensation for urgent care staff will reflect this differential, resulting in higher wage costs for the same staffing.
HCPCS code S9088 is an “add-on” code that allows urgent care centers to receive reimbursement for a portion of this increased cost of rendering service.
What clinics may use S9088?
Any urgent care center can use this code. Some primary care offices need to fill open slots during the day, so they may accept walk in patients, during standard business hours. Although these clinics may use the label of “urgent care,” they obviously do not qualify as bone fide urgent care centers. The actual question is this: “What makes a clinic and ‘urgent care center.'” An urgent care center, as defined by the Urgent Care Association of America, is an walk in medical clinic (offering at least plain-film radiology and CLIA-waved labs) that is open to the public for walk-in, unscheduled visits during all open hours and offering significant hours beyond the typical 9AM to 5PM, Monday through Friday. Some payors have outlined more specific requirements, including ACLS certified personnel, on-site inspections, crash cart with specific supplies, and facility credentialing. Colorado regulations specify fairly stringent regulations for an urgent care center to qualify to bill this code for workers compensation cases. Arizona requires all urgent care centers to be licensed by the state. Other states and payors may have other requirements.
What types of visits qualify for this S9088?
An urgent care center can use S9088 for unscheduled, walk-in visits to the urgent care center.
May I use this code for billing Medicare?
Never code S9088 for billing Medicare. By definition, S codes are codes that are never used to bill Medicare or Medicaid payors.
Is S9088 a global code for the visit, or may the biller code and evaluation and management code, procedure codes and supply codes in addition to S9088 for a given claim?
S9088 is an “add-on” code. It should not be confused with S9083, which is a global code, covering the entire urgent care visit with a single code and a set payment, which is the same whether the patient has a hangnail or a heart attack. Thus, unless restricted by contract or regulations, billers may add this code to a claim, containing other billed codes.
How can an urgent care center demand that a payor reimburse for S9088?
Unless the payor is bound by contract or state regulation to pay for this code, an urgent care center can not force a third-party payor to forward payment. More-and-more payors across the USA, however, are beginning to recognize the importance of and expense involved in providing quality urgent care services to their beneficiaries. Thus, reimbursement is becoming standard policy for many national payors. When an urgent care center is negotiating a contract with a managed care organization, it may make good sense to make sure that payment for this code is specified in the contract.
What reimbursement level should be expected for code S9088?
Reimbursement levels are quite variable by payor. We recommend that you consider the reimbursement rate for S90988, when negotiating a contract with a managed care organization.
The State of Colorado fee schedule for workers compensation sets the fee at $75, but centers must meet certain criteria, and this code is not used for non-urgent visits from 8AM to 5PM, Monday-Friday nor is it to be used for recheck visits of injuries covered under the Colorado workers compensation act (see the act at http://www.colorado.gov/cs/Satellite?c=Page&childpagename=CDLE-WorkComp%2FCDLELayout&cid=1251567882636&pagename=CDLEWrapper).
Note: This information is for coding educational purposes only and should not be used as a clinical guide or as a guide for any specific coding scenario. The user of this information specifically releases Practice Velocity, LLC from any liability or potential liability that might arise as a direct or indirect consequence from reading the information contained on this website.