Urgent Care Coding Guide for Healthcare Professionals

A Detailed Overview Of Urgent Care Coding

Urgent Care services are legitimate medical services required for an illness or injury that would not result in further death or impairment if treated immediately but needs professional attention. It can potentially develop a threat if treatment is delayed for more than 24 hours. A wide range of diseases require urgent care, but a few are as follows.

• Nausea                                                          
• Backache
• Pneumonia
• Conjunctivitis (Pink eye)
• Rash
• Diarrhea
• Sinusitis
• Infection of the ears

Urgent Care centers are rapidly expanding as the healthcare industry evolves. Their ability to provide swift, low-cost and adequate medical care influences their prominence. At the same time, Urgent care billing and coding are more complex than other medical billing and coding scenarios due to unpredictability in patient flow and the fast-paced environment.

Urgent Care Billing and Coding Concerns

Urgent care centers face numerous billing and coding challenges:

Coding: The coding guidelines for urgent care are nearly identical to those for primary care. Providers must appoint the appropriate code for the medical service delivered while also adhering to insurance company rules.

Time limitations: Providers in urgent care do not have time to wait for insurance preauthorization and verification before offering services.

Medicare limitations: Although Medicare covers 80% of urgent care costs, this coverage is lower than that of private health insurance in terms of urgent care reimbursement.

Coding Guidelines for Urgent Care Billing

A physician in urgent care is required to know coding guidelines. A physician needs to code an encounter accurately and efficiently so that patients can receive appropriate service reimbursement. The CPT manual is a set of codes used by physicians and other healthcare providers to report procedures and services they provide. The codes are arranged by specialty, diagnosis, body system, or procedure type. 

After completing a patient encounter, a coder usually translates all diagnoses and processes into medical code sets that are universally used in the healthcare industry (i.e., ICD 10, CPT). ICD-10 codes provide a diagnosis, whereas CPT codes appoint any procedures a provider uses while providing care. CPT codes are combined with ICD (diagnosis) codes to generate patient bills. CPT codes are classified into three categories: 

Category 1 codes are the most popular, which cover disease evaluation and management, surgery, radiology, pathology and lab testing, medicine, and anesthesiology.

Category 2 codes are additional quality assurance codes that do not replace Category 1 codes.

Category 3 codes are for new procedures and technologies that the FDA still needs to approve.

Basic Codes 

The billing processes for Urgent Care and Primary Care are nearly identical because the problems treated by both are identical. However, a few medical codes are unique to Urgent Care Billing. These codes begin with the letter “S.” Urgent Care billing uses codes that start with an “S.”

Two primary code groups pertain to all Urgent Care services apart from Medicare.

S9083: This code allows Urgent Care to charge a single service fee regardless of the patient’s treatment plan. In some cases, a managed care organization (MCO) may require a hospital to bill using the S9083 Urgent care billing code. Several MCOs in states such as Florida and Arizona need urgent care to bill all services under S9083.

S9088 is also known as services provided in an urgent Care center (list in addition to code for service). It allows urgent care centers to bill for medical diagnosis and treatment while admitting that services provided in an Urgent Care facility are inherently more cost prohibitive. The S9088 code must be used with the appropriate evaluation and management (E/M) code. The Urgent care billing code S9088 allows centers to be reimbursed for some of the elevated costs associated with providing urgent care.

The Most Common CPT Codes for Urgent Care

E/M codes account for the majority of CPT codes in Urgent Care centers. These codes can be used to bill patients and insurance companies for services rendered. Various types of doctors who provide urgent care also use these codes. According to CPT assistant, which offers billers and coders industry-recognized guidelines, most urgent care medical billing CPT codes fall between 99202-99205 and 99211-99215. It is important to remember that billing with ER-designated CPT codes is not permitted because urgent cares bridge the gap between a primary care office and an emergency department, posing a compliance risk. The following are some of the most commonly used CPT codes in an urgent care setting: 

CPT Code 99202: This code is used for New Patient Office or Outpatient Services with a time duration of 15 – 29 minutes. An office or other outpatient visit for evaluating and managing a new patient includes the following three key components: a comprehensive problem-focused history, a comprehensive problem-focused investigation, and streamlined medical decision-making.

CPT Code 99203: This code is used for a new patient office visit or other outpatient services for 30-44 minutes. An office or further outpatient visit for evaluating and managing a new patient includes the following three key components: a detailed history, a detailed examination, and low-complexity medical decision-making.

CPT Code 99204: It is one of the most commonly used codes in an Urgent Care setting for new patients with a time duration of 45-59 minutes. It necessitates three critical criteria: a thorough history, a thorough review, and moderately complex medical decision-making. It has a relatively high reimbursement rate with a low risk of noncompliance.

CPT Code 99205: This code is for New Patient Office or Other Outpatient Services with a time duration of 60 – 74 minutes. Office or another outpatient visit for the evaluation and management of a new patient requires three key components: a thorough history, a comprehensive investigation, and high-complexity medical decision-making.

CPT Code 99212: This code is for established patient office visit office with a time duration of 10-19 minutes or another outpatient visit for the evaluation and management of a pre-existing patient that necessitates a medically appropriate history and examination as straightforward medical decision-making.

CPT Code 99213: This code is for an existing patient with a duration of 20-29 minutes which requires care but is less complicated than code 99214. It is one of the most commonly used codes because it makes meeting reimbursement requirements easier. Moreover, it frequently reimburses less than 99214.

CPT Code 99214: According to the American Medical Association, diagnosis code 99214 is for “office or other outpatient visits for the assessment and management of an established patient with the time duration 30-39 minutes, requiring at least two of these three key elements: a detailed history, a detailed examination, and medical decision-making of moderate complexity.

CPT Code 99215: This code is used for patient Office or Other Outpatient Services, lasting 40 – 54 minutes. An office or other outpatient visit for evaluating and managing an established patient includes at least two of the following three key components: a thorough history, a detailed examination, and high-complexity medical decision-making.

ICD-10 Coding For Urgent Care Billing 

The International Classification of Diseases (ICD-10) is a system of organized disease codes which provides a standardized way to classify all diseases, injuries, and other health problems. The ICD-10 coding system allows us to code everything from standard to uncommon conditions because every condition has a unique code. If you have an urgent care visit and your doctor uses the ICD-10 coding system to bill your insurance company, they’ll be able to make sure that you’re correctly reimbursed for all of your treatment.

Urgent care is an excellent option if you have an urgent medical need and don’t have time to wait for your regular doctor’s appointment. However, if you’re hoping to get reimbursed by your insurance company, you’ll need to ensure that your urgent care visit is coded correctly. ICD-10 codes are used in the billing of urgent care visits. If you don’t have a valid ICD-10 code, it will be hard for your insurance company to pay for the services rendered at your urgent care clinic. Most urgent care centers use the ICD-10 codes to bill hospital services. This way, the centers can get paid for their treatments promptly.

Conclusion 

Although urgent care and primary care have many coding standards in common, it is the coder’s responsibility to select the urgent care billing codes that are most relevant for a given medical treatment while also ensuring that the codes comply with regulatory requirements. Before filing a claim, urgent care bills must also follow specific insurance company regulations. If this requirement is not met, urgent care claims will most likely be rejected.