Corporate Compliance

CPT coding for urgent care clinics

Compliance Monitor, July 29, 2005

Q: I'm hearing several different responses to the issue about urgent care "visits" and what current procedural terminology (CPT) codes should be used for these services. Would it be a compliance risk to charge/bill CPT codes 99281-99285 instead of 99211-99215 for urgent care (clinic) visits? Thank you.

A:To answer this question, first let's examine the definition of urgent care.

The Urgent Care Association of America defines urgent care as the "delivery of ambulatory medical care outside of a hospital emergency department on a walk-in basis without a scheduled appointment." In addition, the National Association for Ambulatory & Urgent Care, says, "Urgent Care Centers are walk-in ambulatory care centers, open seven days per week, often 13 or more hours each day, and no appointment is required for a patient to receive care."

Next let's look to CPT Assistant for guidance.

The July 2002 issue of CPT Assistant has the following to say about urgent v. emergency care: "an emergency service is one that is performed in a hospital-based facility that is open 24 hours a day, while urgent care centers are typically non-hospital based and although are open longer than regular physician practices, services are not available 24 hours per day."

In addition CPT Assistant states: "Emergency department codes require reporting for a specific location-the emergency department services not provided in the emergency department should not be identified by ED codes." The guidance goes on to state that a freestanding ambulatory facility or urgent care center visit is not considered an emergency department and that the appropriate codes to use for care rendered in an urgent care clinic are 99201-99215.

This question was answered by Stacie Buck, RHIA, LHRM, vice president of Southeast Radiology Management in Stuart, FL.

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