Questions for Dr. Stern
About Your Urgent Care Center
73. I am in search of documented information to validate or negate a billing question.
The Setting: An office practice such as an urgent care that is owned in
part or all by a hospital and if in part, the other party would be a group of physicians, who may or may not staff the office/urgent care.
The Question: Can such a practice bill Medicare as provider-based (part A and part B) (POS 22) and commercial carriers under part B only (POS 11). I am in hopes we can obtain documentation from Medicare or other carriers that support the answer.
This is a tough question. I have researched this question in the past and came up with the following answer. As far as I know, this answer is correct, but it is a complex legal question, so I would recommend that you get legal counsel before making any final decision.
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 for an urgent care to bill a facility fee, the urgent care should use place of service code 22 (Outpatient Hospital).
Note: Payors generally will not accept a facility fee for place of service codes 11 (Office) and 20 (Urgent-Care Facility).
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