Urgent Care Coding Guidelines 2023 December 16, 2022
You’ve successfully reached your desired number of patients, your online reviews overflow with positive feedback, and your providers offer top-tier patient care. However, your profit margins need to catch up to expectations. If your urgent care practice’s revenue struggles in this aspect, you may need help with your current billing processes.
The solution to this problem is learning the essentials of urgent care billing. You must know the best ways to enhance your billing process and boost your revenue with the right approach.
So, without further delay, let’s discuss the urgent care CPT guidelines for 2023.
Understanding the Urgent Care Billing Process
The urgent care billing process begins at the front door. The billing cycle starts by creating a comprehensible billing policy right at the beginning.
Most urgent care clinics do not have a pre-registration process. However, basic information is collected by the clinic receptionist. The collected data includes the patient’s name, address, DOB, and reason for visiting the clinic. The policy number, primary care provider, and insurance company are also collected.
Data collected from the registration process is used for electronic health records (EHR). All parties involved, such as providers and staff, will work within the EHR to efficiently manage information regarding patient records. Moreover, it makes the billing process smooth and simplified.
The general goal is to increase revenue while spending less on costly collection processes.
Urgent Care CPT Codes
Urgent care facilities are rapidly growing, as reported by Medical Economics. Clinics increased to staggering numbers from 6946 in 2016 to 8285 in 2018. The growth shows providers should stay updated on billing guidelines and coding changes.
Urgent Care Billing Guidelines
Urgent care and primary care offices treat many similar health conditions. Therefore, their billing and coding processes use almost the same codes. However, urgent care uses a specific code starting with the letter S.
S Codes belong to Healthcare Common Procedure Coding System (HCPCS). These codes were primarily assigned by Blue Cross Blue Shield (BCBS). But nowadays, many payers accept them. Moreover, the S Codes are used only by urgent care offices.
The Two Main Options for Urgent Care Coding and Billing Services
S9088
The code S9088, or services provided in an urgent care center – list in addition to the code for service, allows the providers to bill the treatment and evaluation of medical conditions. The code S9088 should always be used with a proper evaluation and management (E/M) code.
Additionally, this code allows urgent care providers to get at least a portion of reimbursement for the increased cost of an Immediate Care office.
S9083
This code is for charging a global fee for the services rendered. Urgent care uses this code regardless of the treatment the patient receives. Some managed care organizations (MCO) may bill a facility under the code S9083.
States that require MCOs to bill providers under S9083
- Florida
- Arizona
Generally, avoiding S9083 is ideal. The reason is based on the global fee-for-service scale. For example, your practice will get the same reimbursement for minor and major cases. The codes S9088 and S9083 account for urgent care visits. You can use these two codes in almost all urgent care encounters.
Medicare is the only exception. Medicare codes depend on reimbursement rates, established medical necessities, and geographic location.
Urgent Care Guidelines
A coder records all diagnoses and procedures once a patient encounter completes. Coders typically use universal medical codes. ICD-10 codes for diagnosis. In addition, the current procedural terminology (CPT) codes for delivering care.
The Three Categories of CPT Codes
Category 1 CPT Code
These codes are the most popular. Their coverage includes the evaluation and management of the following:
- Disease management
- Surgery
- Radiology
- Pathology
- Laboratory testing
- Medicine and anesthesiology
Category 2 Codes
These codes are secondary quality assurance codes that are typically optional. Moreover, they are not used as a replacement for the Category 1 CPT codes.
Category 3 Codes
These codes are used for new and emerging procedures. The category 3 codes still need to be approved by the FDA.
Common Urgent Care CPT Codes
Most CPT codes used by urgent care consist of evaluation and management codes (E/M). Below are the typical urgent care CPT codes.
99214
This code is for a clinic or outpatient evaluation and management of an established patient. Moreover, the patient requires two of three components, such as
- A detailed examination
- Medical decision-making of moderate nature
- A detailed patient history
99213
The 99213 is for existing patients that need treatment. However, the patient should have a similar complexity, like 99214. This code is used frequently because the criteria for reimbursement are easier to complete. On the other hand, it doesn’t reimburse as much as the code 99214.
99204
99204 is the code typically used for new patients in urgent care. It requires three criteria to fulfill, such as
- Comprehensive patient history
- Comprehensive exam
- Medical decision-making of moderate complexity
The code 99204 has a significant reimbursement rate with a comparable rate of non-compliance.
The CPT assistant reported that the most urgent care CPT codes fall under 99202- 99205 and 99211-99215.
Urgent Care CPT Coding Changes
Urgent care CPT codes update every year. Non-compliance could negatively impact claim submission for urgent care providers. Here are the latest changes you should be aware of this coming 2023.
History and exams are not used for E/M service. But it should still be performed to report the CPT codes 99202-99215. E/M code selection is based on the following:
1. The medical decision-making (MDM) level.
2. The time spent doing the service on the same day of the encounter.
The time associated with the CPT codes 99202-99215 changed from the typical face-to-face time to the total time spent with the patient on the day of the visit.
The medical decision-making (MDM) associated with the codes 99202-99215 now has three updated components.
They are:
- The number and complexity of problems managed.
- The amount or complexity of information reviewed and analyzed.
- Two components must be reached or surpassed to select a level of E/M service.
The significant changes in urgent care billing codes include codes and modifiers for the COVID – 19 vaccines.
The CPT codes for this service structure are based on the following:
- The use of intramuscular or subcutaneous injection
- Treatment and management of vaccination complications
Additional Info
Here are the updated modifiers for reporting the activities mentioned above.
- Right side – R
- Left side – L
- Vaccines for children program patients only – VFC
Changes were also made to the HCPCS Level II code set.
Updates for 2023 E/M changes should be your top priority this coming 2023. Remember, the CPT code for an urgent care visit can affect your practice significantly. Find a team that can tap into your true potential.
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