About Your Urgent Care Center

32. I have a question for you guys. I work as an NP for a large chain of free standing private urgent care clinics here in florida. We do have x-ray capabilities, see walk in urgent care, perform physicals, and see various workers comp. patients. We also are contracted with several private insurance companies as well as Medicare, Tricare and some Medicaid plans. We employ mainly physicians, but have a few NPs who work as second providers and occasionally solo in the centers. Recently we have plans to grow and there has been a lot of pressure for us providers to start coding our visits at a higher rate. The problem is that most of our patients are young, healthy, and come in with a single problem for which we have a single diagnosis. (we use E and M problem based coding for all of our visits). Traditionally, we have followed the medicare e and m guidelines for our documentation and coding. Our computer charting that we have now is used only for billing and coding and we scan a single-page minimally narrated check-marked note into the electronic chart. The upper management is assuring us that this single sheet is sufficient for our documentation requirements. There have been rumors that they are going to require that all urgent care patients be coded a minimum of a 99204 level. We usually code at a 99203, and I thought this was a stretch for something simple like pharyngitis in a healthy patient. We are also told that we are no longer allowed to code any 99202 visits. How could we upcode this way with our minimum one-page documentation (with one checkmarked bullet for each system if it is normal)? Is there a way to do this with your computer program? Is this what other urgent care facilities are doing? Also, as an NP, I have been seeing medicare patients for the past year or so and I have never received a medicare UPIN number. If we are to follow the guidelines set by medicare, and in urgent care all urgent care patients are coded as “new”, is it legal to bill medicare for my services since I am an NP and am supposedly not allowed to see new patients? They have never explained this to me. Is there a special rule for urgent care? I would feel better if I knew what other urgent care centers are doing and what an actual 99204 chart looks like.

You ask a lot of interesting questions.

• Documentation: Rule of thumb: Do everything that is appropriate. Document everything you do. Of course, you never document irrelevant systems or body areas.
• Levels of Codes: Let the codes fall where they are appropriate for the above level of documentation.
• Rumor: Level 4 on every new patient? (Of course, it is usually best to ignore rumors, because they are rarely true.) No, our software does not code this way, unless the provider actually documents every patient to a level 4 new patient level, which is essentially impossible to do compliantly as the complexity of medical decision making must be at least moderate for this code. Note: coding this way (100% one high level code) will usually flag a practice for an audit.
• Code every urgent care visit as a New Patient? ABSOLUTELY NOT!!!!!!!!! There is someone out there who encourages urgent care centers to do this, BUT IT IS A BIG MISTAKE. Never, ever do this for Medicare. This is a big mistake. Medicare has recouped big refunds and penalties from practices in the past. For private payors, get it in a contract to do this for any payor. Read my article on this issue at the UCAOA website.
• UPIN: As we understand the rules, all Medicare patients that are seen by an NP (not under incident-to requirements) should be billed under the NP’s provider number.

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