When is an urgent care center allowed to bill a facility code?
Medicare defines a facility as a “hospital-based clinic, a skilled nursing facility, a free-standing surgery center, a comprehensive outpatient rehabilitation facility, or a community mental health center.” So in order to code compliantly, the real question is this: How does a urgent care center meet the definition of a “hospital-based clinic?” That depends on the location and ownership structure of the urgent care center.
A. In the Hospital: If the urgent care center is physically on the facility (i.e., hospital) campus, it is perfectly legitimate to bill the facility fee if the urgent care center meets obligation of hospital outpatient department and the hospital and urgent care center share:
- Same licensure (if available in the state)
- Integrated clinical services
- Financial integration
- Public awareness
B. Off-Campus: Additionally, if the urgent care center is off-campus of the hospital, then the urgent care and the hospital must share:
- Ownership and control
- Administration and supervision
- Location in immediate vicinity
C. Joint Venture: If the urgent care center operates under management contract, then the joint venture must, also, be:
- at least partially owned by the hospital
- located on main campus of the hospital that is an owner
- designated by CMS as being a “provider-based facility.”
In order to for an urgent care to bill a facility fee, the urgent care should use place of service code 22 (Outpatient Hospital).
Payors generally will not accept a facility fee for place of service codes 11 (Office) and 20 (Urgent-Care Facility).
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.