Urgent care centers play a vital role in the healthcare system, providing immediate medical attention for acute illnesses and injuries outside of emergency rooms or primary care physician offices. Understanding the specific coding and billing guidelines for these centers is crucial for healthcare providers and administrators to ensure accurate reimbursement and compliance. This guideline focuses on the essential aspects of urgent care coding, particularly for services rendered in 2022, emphasizing the appropriate Place of Service (POS) code and Evaluation and Management (E/M) coding.
To clarify the scope of these guidelines, it’s important to define what constitutes urgent care in this context.
Defining Urgent Care and Patient Status for Accurate Coding
Urgent Care: An urgent care center is defined as a healthcare facility designed to diagnose and treat acute or episodic illnesses or injuries. These centers cater to unscheduled, ambulatory patients who require immediate medical attention. It is critical to distinguish urgent care centers from hospital emergency rooms, physician offices, or general clinics, as the coding and billing procedures can differ.
New Patient: In coding terms, a “new patient” refers to an individual who has not received any professional services, specifically face-to-face encounters with a physician or other qualified healthcare professional (QHP) within the same group practice and of the exact same specialty and subspecialty, within the past three years. When coding for a new patient in an urgent care setting, the appropriate Evaluation and Management (E/M) code for new patients should be utilized.
Established Patient: Conversely, an “established patient” is one who has received professional services from the physician/QHP, or another physician/QHP of the same group practice and same specialty/subspecialty, within the last three years. For established patients seeking urgent care, the corresponding E/M code for established patients is to be reported.
Billing and Coding Practices for Urgent Care Centers in 2022
For services provided in an Urgent Care Center and processed on or after June 1, 2022, it is mandatory to bill using Place of Service (POS) code 20. Alongside POS code 20, Urgent Care Centers must report the appropriate Office Visit Evaluation and Management (E/M) codes that accurately reflect the level of service provided to the patient. These E/M codes should be selected and applied in strict accordance with the American Medical Association (AMA) guidelines to ensure coding accuracy and compliance.
Furthermore, Urgent Care Centers are permitted to bill for any additional services administered during the patient visit that are distinctly identifiable and separate from the primary E/M service. This allows for comprehensive billing that captures the full scope of care delivered in the urgent care setting.
Limitations and Exclusions in Reimbursement
While these guidelines outline the coding and billing process, reimbursement is ultimately subject to several factors. Payment determination is not guaranteed and depends on, but is not limited to:
- The specifics of the patient’s Group or Individual benefit plan.
- The provider’s participation agreement with the relevant payer.
- Standard claim editing logic, which includes but is not limited to edits for incidental services, mutually exclusive services, payment integrity, and medical necessity.
- Any mandated or legislative requirements, which will always take precedence over general guidelines.
It’s also important to note that for participating providers, patient cost-sharing elements such as co-payments, coinsurance, and/or deductibles will apply based on the member’s benefits.
Historical Updates to Urgent Care Coding Guidelines
To provide context and track the evolution of these guidelines, a brief history of updates is provided below:
| Date | Updates |
|---|---|
| 4/8/2022 | Original Urgent Care coding and billing guidelines created. |
| 4/3/2023 | Annual policy review completed. |
| 2/13/2024 | Annual review completed. Changed “Revised Date:” to “Revision Effective Date:” and added “payment integrity edits” to Limitations & Exclusions. |
| 9/24/2024 | Policy archiving effective December 1, 2024, with policy being integrated into the NDRP-GC-034 Evaluation and Management Policy. |
These guidelines, while archived as of December 1, 2024, provide valuable insight into the urgent care coding practices relevant to 2022 and serve as a foundation for understanding current and future coding policies. For the most up-to-date information, always refer to the latest official coding and billing guidelines and payer-specific regulations.
