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Urgent care billers take note: as of January 1, 2018, UnitedHealthcare (UHC) Commercial in New Jersey and UnitedHealthcare Oxford of New Jersey will no longer reimburse for HCPC code S9083. This won’t remain isolated to New Jersey, however. As we head into 2018, we expect this to grow into a larger trend in urgent care billing as more payers demand proof they aren’t overpaying case rate amounts.

HCPC S9083 is the case rate code “global fee urgent care centers” and is used in urgent care billing as a blanket code to bill for case rate claims. According to a letter UHC sent to providers a few weeks ago, after January 1, 2018, urgent care centers will need to bill fee-for-service–meaning they’ll need to list all the CPT codes for all the services rendered–and UHC will reimburse them at the contracted case rate. Any charges for S9083 billed on a claim after January 1, 2018, will be denied.

For example, a patient visits your urgent care center, and you perform labs and an x-ray. Normally, under your case rate contract with UHC, you’d just bill S9083 and get reimbursed at your case rate amount of $120. However, after January 1, 2018, you’d bill the CPT codes for the office visit, the labs you performed and the x-ray. Even though this might normally be reimbursed for, say, $350 based on the CPT codes you billed, you’ll still only get reimbursed at the flat rate amount of $120.

Why Stop Reimbursing for S9083?

Case rate reimbursement is not as cut-and-dried as it seems. As UHC’s letter suggests by stating code S9083 is “informational,” when an urgent care provider bills every visit using only a blanket code like S9083, you don’t get any utilization information, so it’s tough to track the acuity of care that is being provided at a facility. Because of this, many payers simply can’t tell if the case rate amounts they are paying urgent care centers are appropriate for the levels of services they are providing.

A possible motivator behind UHC’s decision to do away with S9083 is the fear of overpaying on case rate contracts based on the inability to see what levels of services urgent care centers are providing. It’s possible some payors see urgent care centers as retail clinics because they don’t realize urgent care centers provide a higher acuity of care. Without the visibility of services rendered, they may be picturing only strep tests and antibiotic prescriptions when the centers are actually doing labs, x-rays and procedures, so they may see a case rate of $120 as far too high for the level of care being provided. Ending the blanket code S9083 will allow payers to get a better picture of the acuity of care being offered at urgent care centers.

The Future of S9083 for Urgent Care Billing

Will this end with UHC and New Jersey? Highly unlikely. We don’t know for sure why UHC has decided to stop reimbursing for S9083, but if it has anything to do with ensuring they aren’t overpaying providers based on acuity of care, it’s quite possible other payers will follow suit and for UHC to extend this policy outside of New Jersey.

At the very least, urgent care centers should start preparing now for payors who might try to reduce their case rate amounts because they might think they’re overpaying for lower acuity care. The best way to do this is to make sure you have an urgent care billing vendor who can supply you with detailed CPT codes on billed claims so you can show that the acuity of care you have been providing has remained high. Your vendor should be able to pull reports that show a high level of detail, including the procedures, labs and x-rays you’ve been doing. This will prove you deserve the case rate amount you’re already receiving or provide an opportunity for you to negotiate for a higher rate. If your urgent care billing vendor is unable to provide you with this information, it’s vital to switch to one that can.

This resource was first published prior to the 2019 merger between DocuTAP and Practice Velocity. The content reflects our legacy brands.

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