Accidents and non-life-threatening illnesses are often treated at urgent care centers. Urgent care centers can treat episodic patients faster than emergency departments or primary care physicians.
Given the increasing expansion of these services across the US, urgent care facilities must follow the right coding and billing procedures. Urgent care centers must correctly apply CPT (current procedural terminology) codes to receive accurate and timely reimbursement.
CPT codes are a standard numerical system for describing medical services and procedures. Medicare and private insurers have established a reimbursement rate for each CPT code. Correct CPT classification prevents denied claims and underpayment.
2023 guidelines for Urgent care medical billing and coding
Specific critical topics to be aware of are included in the 2023 urgent care medical billing and coding recommendations. Medical billers and coders, especially those in urgent care clinics, must maintain current criteria to classify medical services appropriately. For urgent care facilities, these regulations are crucial since they guarantee that patients are paid what they are entitled to and that medical professionals aren’t overpaying for services.
The Place of Service (POS) code for urgent care facilities has been expressly modified to 20 by the Centers for Medicare and Medicaid Services (CMS). This shift in rules directly impacts urgent care facilities’ coding and billing procedures.
Evaluation and Management (E/M) codes specially designed for urgent care visits have been updated. These codes are necessary to guarantee uniform reimbursement rates and to represent the quality of service rendered by healthcare professionals.
CMS has instituted a new policy emphasizing “Electronic Claim Submission” to decrease claim submission mistakes. The fact that the claim filing procedure has been streamlined lends extra weight to this improved implementation.
List of urgent care CPT codes
Urgent care CPT codes belong to groups 99202–992215, Office or Other Outpatient Services:
- Codes for New Patient Office or Other Outpatient Services: 99202–99205
- Codes for Established Patient Offices or Other Outpatient Services: 99211–99215.
99202: Outpatient Services or New Patient Office
A comprehensive problem-focused history, examination, and simple medical decision-making are all part of this 15–29-minute appointment for a new patient.
99203: Other outpatient services or new patient office visit
A thorough history, physical examination, and simple medical decision-making are all part of this 30- to 44-minute appointment for a new patient.
99204: First visit or other outpatient services
This 45–59-minute appointment for a new patient includes a thorough examination and history and difficult medical decision-making.
99205: New patient office or outpatient services
A thorough history and examination and highly complicated medical decision-making are all part of this 60–74-minute consultation for a new patient.
99212: Patient office visit, established
An established patient will receive a 10-to 19-minute visit that entails a basic medical decision-making process and a medically necessary history and examination.
99215: Patient office visit, established
This is a 20–29-minute visit for an established patient with low medical decision-making and a medically adequate history and examination.
99024: Established outpatient or patient office
This 30-to-39-minute visit for an established patient involves modest medical decision-making and medically relevant history and examination.
Additionally, urgent care facilities are the only ones that fall under two major “S” code categories:
S9083 code: Global fee urgent care clinics use this case rate code. Some payers utilize it to combine all services provided during an urgent care visit into a single international code that applies to all situations and may be reimbursed with a single flat charge.
Code S9088 refers to “services rendered at an urgent care facility (list together with the service code).”
These S-numbers:
- All visits to an urgent care facility with an E/M code are eligible for billing, except for Medicare visits.
- Add-on codes that don’t come with separate billing.
Modifications to CPT codes pertinent to urgent care
Annual revisions from the Centers for Medicare & Medicaid Services (CMS) can significantly affect the claim filing. To file proper claims, urgent care clinics should remain up to speed on code changes and payer laws and regulations. Evaluation and Management Codes, for example, underwent the following modifications in 2021:
- Although the history and exam are not considered when choosing an E&M service, they must report CPT codes 99202–99215.
- While choosing an E&M code, either 1) The degree to which medical decisions are made or 2) The duration of the service on the encounter day
- The usual face-to-face time was replaced with the overall amount spent on the encounter day when defining “time” concerning CPT codes 99202-99215.
- Today, three components make up the medical decision-making factors linked to codes 99202-99215: 1) The quantity and complexity of issues resolved; 2) The volume and complexity of the information that has to be examined and evaluated; 3) The hazards of difficulties, morbidity, or death in patient care. Two prerequisites must be met to select an E&M service level.
Including COVID-19 vaccine-related codes and modifiers will be a major shift to urgent care coding in 2022.
Based on: The CPT codes assigned to this service frame
- Injecting a vaccine subcutaneously or intramuscularly
- Handling vaccination-related consequences
Furthermore, when reporting these services, you must use modifiers like:
- RT, or right side
- Left side, or LT
- VFC: Only patients enrolled in the Vaccines for Children program
The HCPCS Level II code set was modified in addition to receiving new codes and modifiers.
Urgent care’s medical billing and coding challenges
There are several billing and coding difficulties for urgent care centers:
- Coding: The coding standards for urgent care and primary care are nearly the same. In addition to following the insurance company’s guidelines, providers must assign a code suitable for the medical treatment provided.
- Time constraint: Urgent care workers need more time to check with and pre-authorize insurance before providing the service.
- Medicare’s limitations: Medicare pays 80% of urgent care expenses; nevertheless, when it comes to urgent care payment, this coverage is less than that of private insurance.