Guidelines For Billing For Urgent Care Services

Touseef Riaz

June 27, 2022

Billing for urgent care services is significantly different from emergency care services. This kind of care isn’t considered an emergency; however, they do require treatment within 24 hours. 

Urgent care clinics play a vital role in managing the gap between primary care and emergency care. And because the urgent care service is different from an emergency care service, CPT code 99281 can’t be coded for urgent care. CPT code 99281 refers to an Emergency department visit to evaluate and manage a patient. In order to appropriately report this billing for urgent care services code, there are three key components that must be met. They include:

  • A problem-focused history
  • A problem-focused examination
  • Straightforward medical decision-making.

CMS developed an urgent care facility as the Place of Service (POS 20) designation, which has been effective since 2003.

billing for urgent care services

What is the description for POS 20?

According to CMS, an urgent care facility or POS 20 description is as follows:

“Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

(Effective January 1, 2003)”

Billing For Urgent Care Services Codes

The two most commonly used code sets for urgent care include HCPCS and CPT codes. In the case of CPT codes, evaluation and management (E&M) codes are used majorly for reporting urgent care services. The list below are HCPCS and CPT codes used for urgent care services:

Urgent Care Modifier:

Modifier 25 is used for billing for urgent care services

CPT Codes for Urgent care

Urgent care services are coded under the

CPT code 99213

This CPT code falls under Established Patient Office or Other Outpatient Services. According to AAPC:

The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a low level of medical decision making and/or the provider spends 20–29 minutes of total time on the encounter on a single date.

CPT Code 99214

This CPT code falls under Established Patient Office or Other Outpatient Services. CPT Code 99214 is maintained by the American Medical Association (AMA). According to AAPC, CPT code 99214:

The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a moderate level of medical decision making and/or the provider spends 30–39 minutes of total time on the encounter on a single date.

CPT Code 99202

CPT Code 99202 falls under New Patient Office or Other Outpatient Services and is maintained by the American Medical Association (AMA). According to AAPC, this code is reported for urgent care billing as outpatient when:

The provider sees a new patient for an office visit or other outpatient visit involving evaluation and management. The visit involves straightforward medical decision-making, and/or the provider spends 15–29 minutes of total time on the encounter on a single date.

CPT Code 99204

This CPT code falls under New Patient Office or Other Outpatient Services and is maintained by the American Medical Association (AMA). According to AAPC, this code is to report when:

The provider sees a new patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a moderate level of medical decision making and/or the provider spends 45–59 minutes of total time on the encounter on a single date.

HCPCS Codes for Urgent Care Services

S9088:

HCPCS Code for Services provided in an urgent care center (list in addition to code for service). This code is maintained by CMS and falls under Miscellaneous Supplies and Services. HCPCS code S9088 can’t be billed alone, meaning an appropriate evaluation and management service (E&M) code must be billed along with it.

S9083:

HCPCS Code for Global fee urgent care centers. This code is maintained by CMS and falls under Miscellaneous Supplies and Services.

Errors Or Mistakes In Urgent Care Billing And Coding

Even though the billing for urgent care services is booming, the businesses are losing revenues due to errors in medical billing & coding. Some of the common errors in urgent care billing include the following:

  • Poorly managed front desk processes, including checking for co-pays.
  • Incorrect or disorganized documentation
  • Failing to report the valuable charges which ultimately costs the healthcare practice
  • Errors in the medical claims or in filling the claims
  • Other coding errors

Challenges in Urgent Care Billing

Billing for urgent care services is a crucial process for any healthcare practice’ revenue cycle management and smooth functionality. Therefore, like every other healthcare field, urgent care billing also faces several challenges which can directly impact the revenues. Some of the common challenges include the following:

Coding guidelines and regulations

Proper medical billing and coding require following the medicare urgent care billing guidelines as well as fulfilling the insurance payer’s requirements. Now when it comes to urgent care billing, E&M CPT codes are used to report the services rendered as well as HCPCS codes (some are listed earlier). The medical coder is the one who decides which codes should be used, considering the guidelines and requirements. In case the proper coding guidelines and insurance payer’s requirements aren’t fulfilled, the medical claim can be denied or rejected.

Pre-authorization

As mentioned earlier, urgent care treatment/services are required within 24 hours. This time limitation puts a lot of pressure and urgency on the healthcare providers to gather and verify the insurance information. Along with that, confirming the insurance coverage and eligibility of the patient is necessary; however, there isn’t enough time to do so. This is why the healthcare providers can fail to pre-authorize, leading to possible claim denials and rejections. This leads to lost and late payments, lesser revenues, and a lower reimbursement rate.

Medicare coverage

One of the important things for proper medical billing is Medicare coverage. Medicare Part B (Medical Insurance) covers urgently needed care to treat a sudden illness or injury that isn’t a medical emergency. On the plus side, about 80% of the urgent care services are covered under Medicare. For coverage, you will need to meet the Part B deductible. After this, you pay 20% of the Medicare-Approved Amount for your doctor or other healthcare provider’s services. Several urgent care settings accept Medicare coverage; however, some don’t, which can be comparatively less profitable for private insurance payers.

Ways to improve Urgent care billing

Challenges and errors in billing for urgent care services can lead to the claims being denied or rejected therefore affecting the reimbursements. In order to overcome the above-mentioned challenges, the following are some practices that can help.

Confirm and inform the financial responsibility

Medical insurance coverage and eligibility of the patient should be verified beforehand, and if you fail to do so, you can face billing issues. This is the reason why confirm the financial responsibility in the initial stages, so your practice doesn’t face any billing issues after the service is provided. After confirmation, inform the patient regarding their financial responsibility; this enhances trust and satisfaction among the patients. In case the patient’s insurance details aren’t confirmed or verified, present and get a beneficiary notice signed in advance. This notice indicates that the patient will pay the full cost of the treatment services provided.

Complete and accurate documentation

Complete and accurate documentation plays a vital role in medical billing for any healthcare practice. Not just the process, but it is also important in case of claim denials or rejections.

Submit clean claims

Medical claims can be denied in case of errors, non-compliance, and late submissions. These denials result in late payments, lesser revenues, and a lower reimbursement rate for the services rendered by the healthcare physicians.

Medical claims for urgent care have a higher risk of denials than in primary care settings. This is why error-free claims should be submitted in order to minimize the risk and rate of claim denials.

Outsource urgent care billing services

In-house medical billing comes with several other challenges associated with billing. On top of all, it brings higher expenses and a higher risk of errors to the table. However, this can be avoided and managed better by outsourcing the medical billing services to a well-reputed company. The medical billing outsourced services companies have experience and a history of being in the healthcare industry. Therefore, the professional team of medical billers is up-to-date regarding changes in the guidelines for coding and insurance payer’s requirements. 

Why outsource urgent care billing services?

Billing for urgent care services can be quite challenging, demanding, and time-consuming, especially for urgent care. There are several benefits when it comes to outsourcing medical billing services to professional medical billers. One of the major benefits of outsourcing medical billing is the fact that you have an entire team dedicated to managing your billing process. Some of the other benefits of outsourcing urgent care billing services include:

  • The lesser risk of errors in medical claims
  • Faster payments
  • Higher revenues and reimbursement rate
  • Lesser expenses
  • HIPAA Compliance
  • Decreased liability
  • More focus on providing quality patient care

Why UControl Billing?

UControl Billing is a results-oriented and well-reputed medical billing outsourced services company. With UControl Billing, you get:

  • Competitive Pricing
  • Reduced overall expenses
  • Maximized reimbursements
  • Uninterrupted service & stability
  • Faster turnarounds
  • Streamlined workflow
  • Increased cash flows

Services we offer

Revenue Cycle Management (RCM)

Medical Billing Services

Front Office Management Services

Telemedicine Billing Services

Medical Coding Services

Medical Credentialing Services

Medical Transcription Services

What are Urgent Care Services?

It might be difficult to differentiate between a condition that can be categorized as emergency care or urgent care. For any emergency care or medical condition, an emergency room is used. And medical conditions of this nature can be categorized as life-threatening. However, any medical condition, injury, or illness that is not life-threatening but requires treatment within 24 hours is an urgent care service. 

Emergency care Vs. Urgent Care:

Conditions that need emergency care

Any medical condition that can be life-threatening or can permanently endanger your life needs emergency care. Following are some of the conditions that need emergency medical attention:

  • Uncontrollable or heavy bleeding
  • Deep wounds (knife or gunshot)
  • Seizures
  • A fracture that results in the bone protruding through the skin (also known as a compound fracture)
  • Problems related to pregnancy
  • Poisoning
  • Burns (moderate to severe)
  • Serious injury to the neck, back, or the head
  • Difficulty breathing or severe chest pain
  • Symptoms of stroke
  • Weakness
  • Slurred speech
  • Confusion
  • Sudden numbness
  • Vision loss
  • Symptoms of heart attack:
  • Chest pain that lasts more than two minutes

Conditions that need urgent care

Urgent medical billing care is needed for the medical conditions that don’t require emergency care; however, they do need treatment within 24 hours. Following are the conditions that require urgent care:

  • Accidents
  • Falls
  • Mild to moderate breathing difficulty
  • X-rays, laboratory tests, or other diagnostic tests
  • Fever or flu
  • Redness or irritation in the eye, skin infections, or rashes
  • Minor fractures or broken bones of the fingers or toes
  • Severe cough or sore throat
  • UTIs – Urinary tract infections
  • Dehydration, diarrhea, or vomiting
  • Strains, sprains, or moderate back problems

Frequently Asked Questions (FAQs)

1. What is the common billing for urgent care billing errors?

Common errors or mistakes in urgent care billing include the following:

  • Poorly managed front desk processes include checking for co-pays.
  • Incorrect or disorganized documentation
  • Failing to report the valuable charges costing the practice
  • Errors in the medical claims or filling the claims
  • Other coding errors

 2. What is billing for urgent care services?

Urgent care services are significantly different from emergency care services. This kind of care isn’t considered an emergency; however, they do require treatment within 24 hours. And because an urgent care service is different from an emergency care service, CPT code 99281 can’t be used for urgent care services.

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