Urgent care centers are designed to handle non-emergency medical issues that require prompt attention. Effective billing and coding are crucial for ensuring timely reimbursements and maintaining financial health.
This blog delves into the critical role of CPT codes in urgent care settings, offering an up-to-date list of common CPT codes, S codes, and modifiers for 2024. Additionally, we will explore the latest billing guidelines and best practices to help your facility navigate the complexities of urgent care coding and billing efficiently.
What are Urgent Care CPT Codes?
Urgent care CPT Codes are a set of current procedural terminology codes specifically used in the billing and documentation of medical procedures, diagnostic tests, and patient evaluation in an urgent care facility. These codes help the payers understand the circumstances under which the service was delivered.
In urgent care, CPT codes cover a range of services, including:
- Evaluation and Management (E/M) Codes: For documenting patient visits, including new and established patients.
- Diagnostic Testing Codes: For laboratory tests and imaging services like X-rays and ECG.
- Procedure Codes: For minor procedures such as wound repairs, splinting, and casting.
- Immunization Codes: For vaccines and related services.
- Injection and Infusion Codes: For administering medications or fluids.
Why CPT Codes Matter in Urgent Care billing?
Every step matters for the smooth functioning of a healthcare billing procedure. CPT (current procedural terminology) plays a vital role in urgent care as they facilitate standardized reporting of immediate, non-emergency medical procedures, allowing the timely reimbursement for all the services rendered by the healthcare providers.
Urgent care settings handle a wide range of services, from minor injuries to diagnostics, making them prone to coding errors that lead to claim denials. Using the correct CPT codes reduces claim denials or rejections, enhances the clean claim rate, and helps the urgent care facility to maintain financial stability.
Common Urgent Care CPT Codes
In urgent care settings, accurate coding is essential for effective billing and reimbursement. Below is a list of frequently used CPT codes that cover a range of services commonly provided in urgent care:
Evaluation and Management (E/M) Codes
These are used for patient visits based on complexity.
- 99202-99205: New patient office visits (revised in 2021 to focus more on medical decision-making).
- 99211-99215: Established patient office visits.
Procedure Codes
For minor surgeries or injury-related treatments:
- 12001-12007: Simple wound repair (superficial wound closure in various body parts).
- 29000-29750: Casting, strapping, and splinting procedures.
Diagnostic Testing Codes
Diagnostic codes used frequently in urgent care include:
- 71045: Single view chest X-ray (often used for respiratory conditions).
- 81002: Urinalysis, non-automated, without microscopy.
- 93000: Electrocardiogram (ECG or EKG) with complete interpretation and report.
Injection and Infusion Codes
For injections and IV treatments:
- 96372: Therapeutic, prophylactic, or diagnostic injection (e.g., medications or vaccines).
- 96360: Intravenous hydration infusion, initial 31 minutes to 1 hour.
Immunization Codes
Used for the administration of vaccines:
- 90471: Immunization administration for one vaccine.
- 90472: Immunization administration for each additional vaccine.
Exclusive S Codes for Urgent Care Billing Process
S codes are sometimes used in the urgent care billing process. This happens when certain services are not covered by the traditional CPT Codes.
These codes are a part of the Healthcare Common Procedure Coding System (HCPCS), and they are primarily used by commercial payers rather than Medicare or Medicaid.
Here are some common S codes used in urgent care:
- S9083 – Global fee for urgent care centers.
- This code is used when the urgent care facility charges a flat or bundled rate for services provided during the visit, regardless of the specific treatments or procedures.
- S9123 – Nursing care, in the home; by registered nurse, per hour.
- While typically used for home health care, some urgent care settings may use this if they provide home-based urgent care services.
- S9088 – Services provided in an urgent care center (list in addition to the code for service).
- This code is often used to indicate that a procedure or treatment was performed in an urgent care setting and is billed alongside other CPT or HCPCS codes.
- S9124 – Nursing care, in the home; by licensed practical nurse (LPN), per hour.
- Similar to S9123, this is for licensed practical nurse care provided outside the urgent care facility.
These S codes don’t have a universal acceptance but are used by some private insurance companies for urgent care. So, verify with the payer first and then apply it in the billing process.
Common modifiers used in urgent care billing?
Modifiers are necessary in urgent care billing because multiple services are delivered to the patient in the same visit, repeat services, or when services are separated from evaluation and management components.
Here are some common modifiers used in urgent care billing:
Modifier -25: Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day
This modifier should be applied when an evaluation and management service (E/M) is provided on the same day as another procedure yet remains distinct and apart from it.
Example: A patient comes into your office seeking to repair a laceration but also needs evaluation for cough. You would bill both evaluation and management codes (E/M) with modifier -25 for evaluation and management (and procedure code) of their condition(s).
Modifier -59 for Distinct Procedural Service
The modifier -59 is used to indicate two or more procedures were completed that do not usually fall within the same reporting category, yet are appropriate given their circumstances.
Example: If a wound repair and unrelated diagnostic test are provided during a visit, modifier -59 can be used to indicate their separation.
Modifier 24: Unrelated E/M Service during Post-Operative Period
This modifier is applied when a patient returns to an urgent care center for an unrelated E/M service within their global postoperative period, unrelated to previous surgery or treatment.
Example: An existing fracture patient returns for an evaluation for an unrelated illness that does not relate to initial fracture treatment, using E/M services not related to initial treatment of fracture.
Modifier 76 for Repeat Procedure by Same Physician
Use when repeat procedures occur on the same day and by the same physician; this indicates the procedure was necessary and indicates it required repeating for clinical reasons.
Example: The patient receives a repeat X-ray or diagnostic procedure during the same visit due to clinical necessity.
Modifier -51 for Multiple Procedures
When multiple procedures are conducted during one encounter, modifier-51 is applied to secondary procedures.
Example: A patient receives treatment for both fracture and removal of foreign body from wound, with fracture being considered primary and foreign body removal billed with modifier -51 as secondary procedures.
Modifier: 52 Reduced Services
Modifier -52 indicates when services or procedures have been reduced or canceled at the provider’s discretion, for instance when starting but abandoning a procedure prior to completion; modifier -52 shows this fact.
Example: When surgery has been decided upon but other decisions have yet to be made (for instance, when starting but abandoning, this indicates reduced services were rendered by their providers).
Modifier -57: Decision for Surgery
This modifier should be applied when an E/M service leads to the initial decision for surgery.
Example: In an urgent care facility where a patient was evaluated and determined that immediate surgery was required based on what was discovered during an assessment process.
These modifiers are essential in clarifying the details of services rendered, ensuring correct billing, and minimizing claim denials. Adopting them allows urgent care centers to fully capture all services offered while being adequately compensated for their efforts.
2024 Guideline for Urgent Care billing and Coding
The 2024 guidelines for urgent care centers’ billing and coding systems include some modifications with the goal of improving capability, credibility, and efficacy. The specific focus of these guidelines is on modifying Evaluation and Management (E/M) codes, introducing new CPT codes, establishing rules for telehealth services, and altering documentation practices.
Below is a brief description of the most crucial changes for the 2024 model:
Updated Evaluation and Management (E/M) Codes
Like the 2021 update, the 2024 guidelines also focus on the use of MDM or time coding for E/M services. These apply to new and established patient visits:
- 99202-99205: New patient office visits, based on the complexity of the visit.
- 99211-99215: Established patient office visits, using MDM or total time spent.
Telehealth Services
As the use of telehealth increases in physicians’ practices, 2024 implemented new and revised definitions for the CPT codes and included even more codes for telemedicine services. This ranges from virtual consultations to remote assessments for patients needing urgent care.
Proper modifiers, such as modifier -95, must be applied to telehealth services to ensure proper reimbursement.
Chronic Care Management (CCM) Codes
Urgent care centers providing ongoing care for chronic conditions will need to familiarize themselves with the updated chronic care management codes:
- 99490: For at least 20 minutes of clinical staff time spent managing a patient’s chronic condition.
- 99439: New for 2024, this code allows billing for additional time spent beyond the minimum CCM requirements.
Global Fee Coding (S Codes)
In particular, urgent care centers that have adopted S9083 for global fee billing purposes must now follow the payer rules that are emerging with a new demand for detailed reporting of the services falling under the bundle fee.
Medical Necessity and Documentation
The 2024 guidelines continue to emphasize the need for proper documentation of medical necessity in all the procedures and services that are charged. Coders and providers need to ensure that documentation substantiates the CPT codes used, especially in high-complexity visits, procedures, and diagnostic tests. Lack of proper documentation or documentation with wrong information may cause a lot of problems, like denial of claims and audits.
New Codes for Diagnostic Testing
There are new CPT codes for diagnostic tests that are commonly used in urgent care:
- 87636: Respiratory pathogen panel (RPP) for testing multiple respiratory viruses.
- 80305: New code for drug screening via optical observation.
COVID-19 and Vaccination Codes
As COVID-19 becomes a routine part of urgent care, vaccination and diagnostic codes continue to evolve:
- 91309: COVID-19 vaccine administration for updated formulations.
- 87428: COVID-19 testing for combined viral pathogens.
Modifier Usage
Modifiers remain crucial for coding accuracy, and the 2024 guidelines clarify usage for commonly used modifiers in urgent care:
- Modifier -25: Must be accompanied by clear documentation when billing for an E/M service in conjunction with a procedure.
- Modifier -59: For distinct services that are not typically billed together, but must be documented clearly to avoid denials.
Conclusion
In conclusion, accurate and efficient coding is crucial for the success of any urgent care facility, directly impacting billing accuracy and reimbursement. At Medheave Medical Billing Service, Urgent Care Billing and Coding Services are delivered by the best team who will work closely with your practice needs. Our professional staff is knowledgeable about current coding standards and payer rules, so each service is accurately documented and billed. MedHeave Medical Billing Services will ensure you concentrate on patients’ care delivery as we sort out revenue cycle management issues and reduce claim denial rates.
For further details, contact us at (888) 487-1178 or visit our website, www.medheave.com.
