Demystifying Urgent Care Billing HCPCS codes S9083 and S9088

Owing to its unparalleled importance, urgent care billing necessitates keen attention. However, the complicated yet essential procedures of urgent care coding make it challenging to navigate. In particular, understanding the HCPCS codes S9083 and S9088 is necessary for accurate and efficient billing in urgent care settings. Though it is not recommended by many professionals as they hold drawbacks, still many providers and payers use it. Coding is an essential pillar of billing, and when it comes to urgent care billing, adequate compensation depends on the appropriate use of HCPCS codes S9083 and S9088. Though the field of S-codes is relatively unexplored, this article will give you a glimpse into what these codes are, how to use them, their drawbacks, and whether modifiers can be used with them or not.

HCPCS code S9083

S9083 is a Healthcare Common Procedure Coding System (HCPCS) code that combines all the services that are provided during an urgent care visit into a solo, flat-rate fee for urgent care billing. Regardless of the magnitude of the service, the fee charged remains the same. It is practiced by some payers and managed care organizations (MCOs). However, CMS lists the code but has never employed it for claims submitted to Medicare.
The motive behind using HCPCS Level 2 code S9083 is to minimize the coding staff's administrative burden by bundling payments to smoothen the billing process. This is because S9083 is used to bill all the services rendered in an urgent care facility. For a better understanding, consider a hypothetical situation where a patient's initial evaluation and management is succeeded by services such as lab tests, imaging studies, and medication. Instead of individually billing for each service, S9083 facilitates a single, case-rate payment that encompasses the entire encounter. The code is also known as Global Fee for Urgent Care

Billing Guidelines for S9083

One must follow the following guidelines for the appropriate billing of S9083 in an urgent care setting.

• While billing remember HCPCS code S9083 encompasses most services usually rendered in immediate care facilities, including Basic Lab Tests, E/M services, Simple Radiological Scans, Injections, and other minor procedures such as wound care.
• The approach towards using S9083 must align with payer requirements. You must check whether they deem it necessary when it can be used, the specific reimbursement rates associated with it, and the flexibility regarding its usage.
• Its use should be backed by sufficient documentation that includes the Chief complaint and history of present illness, physical examination findings, assessment and diagnosis, plan of care, including all services provided, and time spent with the patient. These details are necessary to receive a just reimbursement.
• S9083 should be a primary code that a modifier can never accompany. However, services that do not fall under the umbrella of S codes will be billed separately concerning their codes.
• Conduct training sessions led by industry experts to keep your staff up-to-date with the latest changes in the highly complicated field of S codes. One must observe compliance at all times.
• Negotiate in the first place with the payers to avoid conflict of interest in the future.

Reimbursement Considerations for S9083

HCPCS code S9083 is used when there is a mutual agreement between the provider and payer that reimbursement for agreed-upon services will be based on a flat rate ( global fee). The claim will be rejected and reimbursement delayed if S9083 is used with an E/M service code unless the insurers allow it. Reimbursement relies on the settled Global fee rather than the magnitude of the service rendered. Global fee can vary depending on the geographic location, patient demographics, and contract negotiations. One must emphasize the quality and efficiency of their services to secure favorable reimbursement rates. To ensure that you receive a fair reimbursement, persuade payers to exclude high-value services that are otherwise buried within the global fee.

Can Billing modifiers be used with S9083

Billing modifiers cannot be used with S9083 in urgent care billing. The main reason for this is that modifiers are used to further describe the particular aspects of a service, whereas HCPCS code S9083 is used to bundle all services under one code. Using modifiers with it can result in the following complications:

• Any modifier attached to S9083 will be declared double billing as the code already includes the billed components. The claim will be rejected.
• Payers who have allowed for the usage of S9083 have agreed upon a specific flat fee. Using a modifier will be considered a direct violation that can lead to audits.
• Modifiers are meant to clarify details. However, S9083 is a comprehensive code, so employing modifiers will only result in redundancy.

Exclusion Criteria for Services from S9083

Not all services rendered in an urgent care facility are billed using S9083. The benchmark set for inclusion and exclusion of services is inspired from the following points.

• Services that are complicated and require sufficient resources should not be billed using S9083. Elsewise the provider will not receive fair reimbursement that will cause financial strain.
• Services that hold the key for planning a treatment should not be charged using a flat-fee strategy. Excluding these would emphasize the unique value they hold.
• Separating some services helps in better tracking of their utilization, costs, and outcomes. This helps public health and other healthcare sector professionals in analyzing their trends and make policies accordingly, e.g Knee Replacement Strategies. When they have data on various patients who have experienced these surgeries, they would better identify what implants are better.

Drawbacks of using S9083

Not everything associated with HCPCS S9083 benefits the provider and payer. Flat-Fee approach does hold some drawbacks that all parties involved in urgent care billing should address before striking a deal regarding S9083. They include

• As we know that S9083 charges the same amount for all the agreed upon services,there is an increased fear of one receiving inadequate reimbursement for complicated and time taking procedures.
• With the flat-fee strategy it becomes difficult to reach a point of agreement as both parties want to protect their interest.
• The bundled payment system may influence the providers to avoid complicated procedures or referring them to other facilities, impacting the level of care provided.
• It is not recognized by Medicare.

HCPCS code S9088

S9088 is a Healthcare Common Procedure Coding System (HCPCS) add-on code used with an E&Mt CPT codes following the proper CMS guidelines to depict that services were provided in an urgent care facility. Some payers accept that services rendered in an urgent care facility deserve more compensation than those provided in a primary care center. Many payers and Managed Care Organizations recognize this code. However, it is neither recognized nor reimbursed by Medicare or Medicaid.

Description for S9088

Here's a detailed description for HCPCS code S9088, incorporating insights from current best practices:

• HCPCS Code: S9088
• Code Title: Services provided in an urgent care center (list in addition to code for service)
• Purpose: To capture the unique costs and services associated with urgent care centers, distinct from traditional office visits.
• Applicability: May be used for all unscheduled, walk-in visits to urgent care centers.
• Reimbursement: Not recognized by Medicare, but often reimbursed by private payers.

Billing guidelines for S9088

The guidelines for HCPCS code S9088 are as follows

• S9088 is typically billed in addition to the appropriate Evaluation and Management code depicting the care level provided.
• As there is no flat-fee scenario, verify the reimbursement policy firsthand with the payer.
• Never use S9088 on claims submitted to Medicare if you don't want to see them rejected.
• Documentation must include the reason for the urgent care visit, services provided, and time spent.
• Some payers may ask for additional requirements if you wish to use it.

Reimbursement considerations for Urgent Care Code

S9088 is used to compensate for unique costs associated with urgent care facilities. There is no fixed reimbursement rate as compared to S9083. S9088 reimbursement rate varies from payer to payer and depends on geographical location and demography. A prior agreement that serves the mutual interest of both parties should be reached. Always remember that S9088 can be reimbursed for all unscheduled walk-in visits, encompassing the majority of services rendered in an urgent care facility. Ensure that your coding practices are compliant to avoid potential risks of claim denial.

Can billing modifier be used with S9088

Billing modifiers can be used with S9088 owing to specific situations. Using them appropriately requires a significant amount of knowledge and understanding on the part of the coder.
Allowed Modifiers:

• Modifier 25: If the patient returns for follow-up related to the original visit within the same episode of care (typically defined by payer policy), you can append modifier 25.
• Modifier 54: This modifier can be used under extraordinary conditions when the procedure performed in an urgent care facility is way too complicated. Appropriate documentation should be present to back this.
• GX Modifier: This modifier can be used with S9088 if the urgent care services are provided outside the physical location of the urgent care center

While the use of the modifiers is justified, still, payer and governing body policies play a vital role in deciding whether the modifiers should be used or not.

Challenges associated with using S9088

Various challenges are faced by the providers when they use S9088. Some of them are as follows.

• As reimbursement varies from payer to payer, it might become difficult for providers to keep track with the fluctuating rates.
• The use of modifiers with S9088 requires attention to detail. One should have sound knowledge regarding the intricate use of modifiers.
• Receiving timely reimbursement for claims submitted via S9088 necessitates pinpoint accurate documentation.
• Medicare does not recognize claims submitted via S9088. Regarding Medicare, alternate codes such as CPT code 99051 should be used to receive compensation for the extra work done.

MedsIT Nexus: Your Partner in Urgent Care Billing

MedsIT Nexus has a reputation for helping urgent care facilities get due compensation for their services. Our coders are well-versed in HCPCS Codes S9083 and S9088. Our advanced claim generation and submission system help us reduce claim denials considerably. MedsIT Nexus has been a long-standing partner of industry leaders and will surely address all your billing woes, helping you ace urgent care billing.