This page is expanded from a column by David Stern, MD, CPC in the Journal of Urgent Care Medicine, December 2006
What are S Codes?
S codes are a set of Healthcare Common Procedure Coding System (HCPCS) codes. These codes were originally requested by Blue Cross/Blue Shield. Many payors and agencies, including managed care organizations (MCOs) and state workers compensation boards, have found these codes useful for defining specific services that are not recognized or reimbursed by Medicare or Medicaid. The codes are listed by the Centers for Medicaid & Medicare Services (CMS); however, billers should never use S codes on Medicare claims.
S9083 – A Case-Rate Code
This code is used by payors to bundle all services rendered in an urgent care visit—whether it be for a hangnail or a heart attack—into a single, one-size-fits-all code for reimbursement with one flat-rate fee. Some MCOs (especially in Florida, Arizona and Southern California) use this case-rate code for urgent care visits.
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. If your urgent care center, however, 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.
Work with MCOs
Clearly, the S9083 code can be a financial problem for urgent cares equipped to deal with more than minor illnesses and injuries. Urgent care centers should make it clear to MCOs that using case-rate coding may force urgent care centers to send higher acuity cases to hospital emergency departments (EDs). Total fees at the ED can run up to 10 times more than the fees for rendering the same services at an urgent care center.
We recommend that, whenever possible, the urgent care center negotiate with the MCO to show that it is in everyone’s best interest to pay for services rendered rather than defaulting to one-size-fits-all reimbursement. Some visits take twenty minutes; others may take more than three hours. If the MCO insists on only paying for twenty minutes worth of work for every visit, then the urgent care provider will need to refer the more resource-consuming cases to other providers in order to avoid financial losses. In the end, this will cost the MCO significantly more than paying the urgent care for services rendered.
Finding the Compromise
If the MCO insists on case-rate (S9083) coding, explain that you can save them the cost of ED and specialist referrals by taking x-rays, treating complex lacerations, and caring for simple fractures. Specify that in order to provide these services you will need a modification to case-rate coding. Ask for a list of “carve-out” codes that the MCO will allow you to use for reimbursement, in addition to the flat-rate code of S9083. Without carve-outs, you will lose money on higher acuity cases, so you will be forced to refer out:
· complicated lacerations to specialists.
· simple finger and toe tuft fractures to orthopedic surgeons.
· any complex care, such as IV hydration or nebulizer treatments for asthmatics, to hospitals.
This extra care will cost the MCO thousands of dollars for every referral. Suggest that certain codes be carved out (at an appropriate fee schedule) and billed in addition to the S9083. Try to get the MCO to realize that without carve-outs, a flat-rate billing structure will not allow the urgent care center to provide one of its major benefits to the MCO and its clients—namely, reducing the inconvenience and expense of hospital emergency department visits.
When to Use S9083
Use this code only when required by contract. An MCO contract may require just that; if so, make sure that you negotiate carve-outs (or an acceptable case-rate) prior to signing the contract. A few Medicaid payors (e.g., Indiana) insist that urgent care providers use this code. In Delaware, freestanding emergency departments (high-level urgent care centers that are equipped to handle all medical emergencies that have life-threatening potential) are required to bill S9083. In these cases, the freestanding EDs receive the exact same reimbursement for any and all visits billed to Medicaid clients through an MCO.