Urgent care centers (UCCs) are a vital part of the healthcare landscape, offering immediate medical attention for non-life-threatening conditions outside of regular primary care hours. As the demand for urgent care services rises, ensuring accurate and efficient medical coding becomes increasingly critical for revenue cycle management. Many urgent care facilities are finding that the optimal solution to navigate the complexities of coding and billing is to Outsource Urgent Care Coding Services.
The urgent care sector is experiencing significant growth. Statistics from Medical Economics highlight this trend, showing an increase in urgent care clinics from 6,946 in 2015 to 8,285 in 2018. The Urgent Care Association (UCA) reports approximately 89 million patient visits annually to UCCs, with a substantial portion, over 29%, being primary care related visits. This high volume necessitates robust coding and billing processes. To secure proper reimbursement and maintain financial health, urgent care providers must stay abreast of constantly evolving coding changes and billing guidelines.
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Understanding CPT Codes for Urgent Care
Coding for urgent care utilizes specific CPT (Current Procedural Terminology) codes within the range of 99202-99215, categorized under Office or Other Outpatient Services. These codes are further divided into new and established patient visits:
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Codes 99202-99205: New Patient Office or Other Outpatient Services – These codes are for new patients and vary based on the complexity of the visit, encompassing time spent and the level of medical decision-making.
- 99202: For visits lasting 15-29 minutes, requiring an expanded problem-focused history and examination, and straightforward medical decision-making.
- 99203: Covers visits of 30-44 minutes, necessitating a detailed history and examination, and low complexity medical decision-making.
- 99204: Applies to visits of 45-59 minutes, requiring a comprehensive history and examination, and moderate complexity medical decision-making.
- 99205: For longer visits of 60-74 minutes, demanding a comprehensive history and examination, and high complexity medical decision-making.
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Codes 99211-99215: Established Patient Office or Other Outpatient Services – These codes are for established patients, again differentiated by visit complexity and time.
- 99212: For visits of 10-19 minutes, requiring a medically appropriate history and/or examination and straightforward medical decision-making.
- 99213: Covers visits of 20-29 minutes, requiring a medically appropriate history and/or examination and low-level medical decision-making.
- 99214: Applies to visits of 30-39 minutes, requiring a medically appropriate history and/or examination and moderate level of medical decision-making.
- 99215: For longer visits of 40-54 minutes, requiring at least two of three key components: a comprehensive history, a comprehensive examination, or medical decision-making of high complexity.
In addition to these E/M codes, urgent care utilizes specific ‘S’ codes:
- Code S9083: Case rate code global fee urgent care centers. Some payers use this to bundle all services within an urgent care visit into a single, flat-rate reimbursement.
- Code S9088: “Services provided in an urgent care center (list in addition to code for service).” This add-on code can be billed with an E/M code for most payers, excluding Medicare, for each urgent care visit. It cannot be billed independently.
Navigating CPT Code Changes in Urgent Care
The Centers for Medicare & Medicaid Services (CMS) annually updates coding guidelines, significantly impacting claim submissions. Urgent care centers must diligently track these changes to ensure accurate claims. For example, 2021 saw substantial revisions to Evaluation and Management (E&M) codes:
- History and physical exam are now components of E&M service but are not the primary factors for code selection (99202-99215).
- E&M code selection now depends on either: 1) Medical Decision Making (MDM) level OR 2) Total time spent on the encounter day.
- The definition of time for codes 99202-99215 shifted from face-to-face time to total encounter day time.
- Medical decision-making elements now include: 1) Number and complexity of problems addressed, 2) Amount and complexity of data reviewed and analyzed, and 3) Risk of complications, morbidity, or mortality. Meeting or exceeding two of these three elements determines the E&M service level.
Significant coding updates in 2022 included new codes and modifiers for COVID-19 vaccinations, covering intramuscular or subcutaneous injection administration and management of vaccination complications. Modifiers like RT (Right Side), LT (Left Side), and VFC (Vaccines For Children program patients only) became essential for reporting these services, along with changes to the HCPCS Level II code set.
Addressing the Complexities of Urgent Care Medical Billing and Coding
Urgent care centers face unique billing and coding challenges:
- Coding Nuances: While sharing similarities with primary care coding, urgent care requires precise code assignment based on services rendered and adherence to specific payer rules.
- Time Constraints: The urgent care environment often lacks the time for extensive insurance preauthorization and verification processes before service delivery.
- Medicare Limitations: While Medicare covers urgent care at 80%, reimbursement rates can be less favorable compared to private insurance in the urgent care setting.
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Given these challenges, outsourcing urgent care coding services presents a strategic advantage. By entrusting coding and billing to specialized experts, urgent care providers can concentrate on patient care. Partnering with a reputable medical billing and coding company ensures accurate, timely claim submissions, leading to optimized reimbursement and a healthier revenue cycle.
Loralee Kapp
Loralee Kapp, HIT Certified and CPC certified by the AAPC, brings extensive expertise in medical coding and health information management to OSI’s RCM Division since October 2021. Learn more about Loralee Kapp
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