Urgent Care Evaluation and Management Documentation and Coding

Presented by: Dr. John Stimler, DO, CPC, CHC, FACEP
Total Run Time: 55:59
AAPC Approved for 1.5 CEUs, Core A, and all specialties except CIRCC and CASCC Specialty Credits Specialty Credits

Urgent Care is the provision of medical and traumatic care in a facility dedicated to more acute care outside of a hospital emergency department. Patients can be treated on a walk-in basis, without an appointment, and receive immediate care. If necessary, stabilization therapy may be provided for emergency condition prior to transfer of a patient to a hospital environment.

Some Urgent Care centers provide services that replicate the great majority of services provided in emergency department. Capabilities may include extensive lab, x-ray and Special Studies such as CT scans and MRIs. The patients evaluated include a large number of moderate to high severity conditions that are “worked up” and managed in an Urgent Care setting.

Higher levels of Medical Decision Making intermixed with appropriately documented Histories and Exams generally result in higher Evaluation and Management code choice. This is especially true when compared with an office-based practice where limited ancillary studies and management options exist. In an Urgent Care setting, appropriate code choice is vital to ensure maximum reimbursement while maintaining compliance.

Topics include:
• Provider documentation requirements for each E/M code.
• How the medical record can influence the chosen E/M code level.
• How the ancillary studies available at each Urgent Care environment allow for management of more acute patients with higher severity conditions.
• Appropriate E/M code choice in an Urgent Care setting.
• E/M code choice distribution comparisons.

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