The Record - for physicians and other health care providers to share with their office staffs
February 2011

Answers to your questions about urgent care center network billing, reimbursement

This section answers questions specific to hospital-owned urgent care centers.

1.       Q. Can hospital-owned urgent care centers still bill for facility charges?
A.  It depends. Hospital-owned physically unattached urgent care centers may not bill for and will not be reimbursed separately for facility charges. Hospital-owned physically attached urgent care centers that do not opt to join the urgent care center network will continue to bill as they do currently under the Participating Hospital Agreement.

2.       Q. What happens if a patient needs laboratory or radiology tests in addition to the services of the urgent care center?
A.

  • If an ancillary service is performed within the urgent care center and performed by a staff member of the UCC, then the urgent care center bills it as part of the UCC visit claim, following the office service guidelines.
  • If the service is performed by non-urgent care center staff using hospital-owned equipment, even if done within the same building where the UCC is located, the hospital may bill that service on the hospital UB claim for the technical service, and a separate professional claim may be submitted for the professional service done in location 22, hospital outpatient.
  • All appropriate cost-sharing will apply based on service type and location.

3.       Q. Can we use our hospital NPI for our off-campus urgent care center?
A. It depends. A separate NPI is not needed if the hospital does not have any other professional PINs linked to that NPI. If, however, you already have professional PINs associated with the NPI, you may want to obtain a separate NPI for your off-campus urgent care center, so we can maintain our ability to process your claims in an accurate and timely manner.

4.       Q. If a hospital-owned physically unattached urgent care center does not meet the urgent care center qualifications, can it still bill BCBSM?
A. Yes, the center can still bill BCBSM. However, it must have an established professional group with BCBSM, and the services must be billed as physician or professional with office as the location of service.

5.       Q. What is the advantage to an attached urgent care center electing to participate in the network?
A. The urgent care center will be listed in our directories on bcbsm.com and bcbs.com, for out-of-state members seeking care in Michigan. The member’s cost-sharing is typically less in the urgent care setting than in an emergency room, so members will most likely choose to visit the urgent care centers in our network.

This section answers your questions for both hospital-owned and nonhospital-owned urgent care centers

6.       Q. We did not complete our application by Dec. 31, 2010. Does that mean we will not qualify to participate at this point?
A. The enrollment process for the urgent care center network is ongoing. You may join the network and be added to the directory at any time.

7.       Q. Does each practitioner in the urgent care center need to complete the New Allied Provider Enrollment Form?
A. No, each practitioner does not need to re-enroll. The urgent care center is enrolled as a professional group with no affiliated practitioners. The only physician information we need on the enrollment form is from the medical director. However, the board-certified physician medical director of the urgent care center is responsible for oversight of medical management at the center in accordance with published BCBSM policies. In addition, all of the practitioners at the urgent care center must be individually enrolled with BCBSM or BCN under their own Type 1 NPIs.

8.       Q. Do these new urgent care changes apply only to BCBSM business lines, or do they include Blue Care Network? What about BCBSM Medicare Advantage plans?
A.These changes apply to BCBSM only. BCN contracts with urgent care centers separately from BCBSM, and BCN maintains its own unique network of providers. Medicare Advantage is not included in this policy change.

9.       Q.  What are the advantages to billing as an urgent care center rather than a physician or professional office?
A.

  • There are four additional radiology codes that urgent care centers can bill for that are not payable in a physician’s office.
  • You do not need to enroll the individual practitioners who practice in the urgent care center.
  • Participation in the urgent care center network will lead to inclusion in the BCBSM and Blue Cross and Blue Shield Association UCC directories.

10.     Q.  What place of service should providers bill on professional claims for dates of service on or after Jan. 1, 2011? 
A.  Providers need to follow the billing rules that apply to their BCBSM participating professional provider type (that is, if not a participating urgent care center). For example, an urgent care center can bill using CMS location of service 20, and a physician’s office can bill using location of service 11.

11.     Q. If our office cannot meet BCBSM urgent care center guidelines, may we still run our office as urgent care and call ourselves an urgent care center?
A. You may call yourselves whatever you wish; however, you will not be recognized as an urgent care center by BCBSM. Only use procedure code S9088 for BCBSM urgent care center claims. 

12.     Q. If we are not an urgent care center according to BCBSM urgent care center guidelines, can we still bill with location code 20?
A. Yes. 

13.     Q.  When should we use procedure code S9088?
A.  Please report procedure code S9088 on all urgent care claims with an evaluation and management code. Procedure code S9088 is not separately payable, but it is needed to properly adjudicate urgent care center claims.

14.     Q. Currently, providers post a “zero” charge on the S code when submitting a claim. Is BCBSM looking to add an allowed amount so there will be a reimbursement on the S code, or is it just used as an informational code?
A. At this time, BCBSM is using the S9088 as an informational code that is not linked to a reimbursement rate.

15.     Q. What are the billing procedures for urgent care centers?
A. Urgent care centers should bill all services electronically using the professional 837 transaction.

16.      Q. What if a physician working in an urgent care center setting wishes to bill services as a physician office rather than a UCC?

A. A physician may bill for non-urgent services if seeing non-urgent care cases.  In that case, the urgent care code S9088 would not be billed, and the individual physician NPI or group NPI would be on the claim, rather than the urgent care center NPI. The location of service would be office, 11, rather than urgent care, 20.

17.     Q. How will urgent care centers be reimbursed?
A. Urgent care centers will be reimbursed for covered services according to the BCBSM  Traditional Fee Schedule for:

  • All medical-surgical codes currently payable in a primary care physician’s office setting
  • The same range of laboratory tests payable in the primary care physician office setting
  • All radiology tests currently payable in the PPO physician office setting, plus four additional codes (*73500, *73510, *73520 and *73540, related to hip X-rays).
  • After-hours codes (if covered by the member’s benefit plan); evaluation and management add-on codes *99050 and *99051 

18.     Q. Can we bill the after-hours codes for services on Saturday even if we have regular hours on Saturday?
A. Saturday may be regular hours for you, but they are billable as after-hours codes.

19.     Q. Does the BCBSM payment go to the urgent care center NPI or to a physician NPI?
A. The payment goes to the urgent care center NPI, not to the individual rendering provider.

20.     Q. Do urgent care centers need to join a separate PPO network to be considered in-network for PPO members?
A. All participating urgent care centers will be considered in-network for PPO members, and out-of-network sanctions will be waived. There is not a separate PPO network requiring enrollment.

21.     Q. Why does BCBSM require a physician on-site during all hours of operation? 
A. To assure quality and to differentiate urgent care centers from retail clinics.

22.     Q. Can a participating urgent care center use an existing professional office practice NPI?
A. If participants want to conduct business as both a professional office practice and an urgent care center, BCBSM recommends a distinct NPI for your urgent care center to maintain our ability to properly adjudicate your claims. Or you may change your existing professional NPI to represent the urgent care center.

23.       Q. Can an urgent care center NPI serve multiple locations?
A. One urgent care center NPI may have additional locations loaded to our records, as long as all the additional locations are payable to the same tax ID number and remittance address. Each additional location will be listed in the UCC directory. So we can maintain our ability to process your claims in an accurate and timely manner, BCBSM recommends that additional locations with separate tax IDs obtain a separate NPI for each tax ID

24.     QCan a certified nurse practitioner bill part of the time as indirect and part of the time directly, under her or his own name?
A. Nothing changes with how a CNP bills in the office setting. What changes is in the urgent care center (location 20) because the NPI belongs to the center, which bills BCBSM. The CNP is considered the rendering provider in that case. The contract is between BCBSM and the urgent care center. The CNP has the relationship with the center.

25.     Q.  Does the urgent care center need to list the practitioner who rendered the service when billing, or does the urgent care center only need to bill with the urgent care center NPI?
A.  We do require that the UCCs report the rendering practitioner’s NPI in field 24J, or the corresponding electronic claim location. Please include the rendering practitioner's license number.

26.     Q.  Does this network include out-of-state centers?
A.  The network we created is just for Michigan. However, we can apply urgent care benefits to claims that come in via BlueCard® from other states.

27.     Q. How does a provider join this network?
A. To enroll as an urgent care center, follow these steps:

  1. Go to bcbsm.com.
  2. Click on Provider on the right side of the page, then More.
  3. Click on Enrollment and Changes in the left column.
  4. Click on Physicians and Professionals, then Next.
  5. Click on Enroll a new provider, then Next.
  6. Go the box titled Allied Provider, choose Urgent Care Center and click Next.
  7. Click on BCBSM agreements and signature documents, review the Urgent Care Center BCBSM Traditional Participation Agreement (PDF) and refer to Addendum B for qualifications.
  8. Click on the New Allied Provider Enrollment Form (PDF).
  9. Complete the proper fields for urgent care centers.
  10. Complete the BCBSM Traditional Urgent Care Center Signature Document (PDF).

28.     Q. If a provider applies and is accepted, how will members know the center is part of the network?
A. We will identify urgent care centers in a provider directory on bcbsm.com and the Blue Cross and Blue Shield Association website starting Jan. 1, 2011.

This section answers your questions specific to nonhospital-owned urgent care centers

29.     Q. If we want to be a clinic during the day and urgent care center at night, and we participate in the Blue Care Network urgent care center network, what do we do with our NPI?
A. A distinct NPI for your urgent care center will maintain our ability to properly adjudicate your claims. The professional group record can be maintained under one NPI, and the urgent care center would be maintained under a second NPI. You can request that the BCBSM Traditional network be added to the existing BCN urgent care center record.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2010 American Medical Association. All rights reserved.