Urgent care medical billing is fraught with numerous pitfalls, and constant payer policy changes put providers’ revenue at risk. Effectively managing current challenges ensures that every provider in the USA receives maximum reimbursement. If your urgent care institution is suffering from revenue collection issues, this blog is for you. We will focus on barriers to accurate billing and coding and how to overcome them easily.
What Is Urgent Care Billing?
Urgent care revenue cycle management involves the billing of patients arriving at a healthcare institution without an appointment. Though these patients are not suffering from life-threatening conditions, they still require immediate medical attention.
Additionally, the urgent care centers face fluctuations in patient incoming, e.g., flu seasons may prompt more elderly and at-risk patients to visit the clinics more often than needed. Due to the large number of patients coming for medical check-ups, urgent care hospitals face an administrative burden on the in-house staff.
Urgent care billing differs in many aspects from other types of medical billing, such as primary care billing and emergency room billing. In terms of unique CPT, ICD-10, and HCPCS coding requirements and documentation, urgent care centers must provide a comprehensive and detailed explanation of medical services rendered to patients in medical claims for reimbursement.
Due to stringent payer policies, many providers offering urgent care medical interventions face claim denials due to incorrect or missing codes. A mistake that’s mostly overlooked is the failure to add modifiers that accurately describe the medical care service provided in an urgent care institution. This leads to complications, with claims being rejected or denied, resulting in a loss of revenue.
Why Urgent Care Billing Is More Complex
There’s no doubt that the urgent care settings have different methodologies in billing their patients due to various reasons, like:
High patient volume
Providers running an urgent care setting face high patient volume due to seasonal effects like the flu, etc. They are also cheaper than emergency room visits, allowing patients to get better medical care without paying high premiums on their health plan for ER check-ins.
Walk-ins with unknown insurance coverage
The second factor that increases the complexity of accurately billing patients is payer mix. Not all patients hold the same health plan. The variability in different insurance policies makes it even harder for in-house billers to understand the billing nuances of Medicare, Medicaid, and private insurers.
Wide range of services (labs, X-rays, procedures)
In an urgent care clinic, various diagnostic services are also available, making the full diagnosis for providers easy and reliable. Medical codes for laboratory tests, X-rays, CT scans, and MRIs are totally different from normal E/M visits. This complicates the billing process even more.
Top Urgent Care Billing Challenges
Here are the top urgent care revenue cycle challenges that may affect your practice, including:
High Claim Denial Rates
One of the biggest urgent care billing challenges is the high claim denial ratio in comparison with the acceptance rate. High-dollar claims add to revenue loss, causing disruption in cash flow.
Lack of Prior Authorization
Common urgent care billing mistakes are failure to obtain prior authorization for procedures that require mandatory approval from insurers. This becomes challenging for walk-in OPD settings where patients arrive without an appointment.
Inefficient Billing Systems or Lack of Automation
The use of outdated billing software or manual claim processing increases the likelihood of errors, resulting in typos, missing critical documentation, and other issues. Billing automation in claim submission, payment posting, and AR tracking resolves such issues.
Coding Errors (CPT, ICD-10, Modifiers)
Urgent care coding is complex, and the intricacies of ICD-10, CPT, and HCPCS coding standards are subject to frequent changes. Urgent care coding tips for higher reimbursement include training in-house staff on the latest practices.
Limited Staff Training in Billing & Coding
Urgent care centers face shortages of trained and skilled medical coding staff. An unskilled RCM team can misinterpret medical codes, payer updates, and miss the claim submission timeline entirely.
Inaccurate Charge Capture
Upcoding or downcoding for any procedure performed at your facility results in underpayments. Outsourced urgent care billing solutions offer prompt solutions to tackle such issues. Inaccurate charge capture damages the financial health of medical facilities.
Essential CPT Codes Used in Urgent Care
Strategies to reduce urgent care claim denials become effective by using accurate and valid CPT medical codes for diagnosis and billing, like:
Common evaluation & management (E/M) codes
The common E/M codes to use in an urgent care patient treatment facility are as follows:
- 99213 — Established Patient, Low MDM
- 99214 — Established Patient, Moderate MDM
- 99203 — New Patient, Low MDM
- 99204 — New Patient, Moderate MDM
- 99212 — Established Patient, Straightforward MDM
- 99215 — Established Patient, High MDM
- 99202 — New Patient, Straightforward MDM
- 99205 — New Patient, High MDM
- 99211 — Established Patient, Minimal Services
Procedure codes
- 10060 — Incision & Drainage of Simple Abscess
- 10061 — Incision & Drainage of Complex Abscess
- 12001 — Simple Wound Repair (2.5 cm or less)
- 12002 — Simple Wound Repair (2.6–7.5 cm)
- 29125 — Short Arm Splint Application
- 29515 — Application of Short Leg Splint
- 96372 — Therapeutic Injection (e.g., antibiotics, steroids)
- 87880 — Rapid Strep Test
- 81002 — Urinalysis, Non‑Automated (Dipstick)
- 71046 — Chest X‑Ray, 2 Views
Best Practices for Improving Urgent Care Billing
Urgent care billing best practices for providers to improve billing workflow and process include:
Verify Insurance in Real Time
Prompt eligibility verification by the RCM staff plays a vital role in urgent care billing workflow improvements. Real-time results ensure the patients receive medical care that’s included in their plan.
Train Staff on Urgent Care Specific Coding
Regular training of in-house staff on current ICD-10, CPT, and HCPCS coding updates enables medical coders to use only accurate codes, resulting in error-free clinical documentation and timely reimbursement.
Track and Appeal Denials Promptly
Outsourcing urgent care revenue cycle management services helps providers in timely tracking claims and filing appeals if necessary. Providers can get a daily update on total denials with ease.
Automate Eligibility Checks
Leveraging automation is how urgent care centers can increase revenue and save valuable wait time for their patients. Insurance eligibility checks in advance increase claim acceptance and prevent surprise billing.
Outsource Billing to Specialists
To tackle the constant demands of insurers, outsourcing fast-tracks the urgent care revenue optimization. Practices can experience reduced risk, penalties, fines, and maximum compliance with state and federal regulations.
How to Maximize Reimbursements in Urgent Care
There are many ways providers in the US can increase and improve urgent care financial performance by taking steps like:
- Improve coding accuracy
- Increase clean claim submission
- Streamline denial management workflows
- Automated claim scrubbing
- Timely follow‑up on unpaid claims
- Avoid undercharging
- Improve payer negotiations
- Enable online & Point‑of‑Service payments
- Reduce claim denials
- Track key metrics (A/Rs, average reimbursement, payer mix)
- Use pre‑authorization where required
- Verify insurance eligibility promptly
Urgent Care Billing vs. Emergency Room Billing: Key Differences
There’s a big difference between urgent care RCM and ER billing from process to procedures. Both serve as vital healthcare facilities for improving the quality of life and offering prompt access to medical care. Let’s dissect the parts where they differ, like:
Key Differences
Urgent care facilities offer medical care for non-life-threatening conditions like minor cuts, skin burns, allergic attacks, infections, etc. Whereas the emergency room centers only deal with life-threatening situations where immediate medical interventions can save lives. ER offers treatment for conditions like heart attack, stroke, etc.
Cost Differences
Similarly, cost-wise, urgent care is more economical than emergency room visits because ERs have trauma surgeons, performing various critical procedures that can increase the cost in billing. Additionally, urgent care doesn’t run 24/7; on the other hand, ERs operate 24/7, 365 days a year.
Final Thoughts
Urgent care billing is complicated and requires specialized knowledge, skillset, and expertise from the billing and coding team. Accurate patient billing is the pathway for getting reimbursed from insurance companies without any deductions. Outsourcing AHIMA & AAPC-certified urgent care coders guarantees an error-free transition from physician notes to the exact corresponding medical code for precise clinical documentation.
Medheave is a HIPAA-compliant medical billing company offering state-of-the-art medical billing services to minor emergency clinics across the US. We help medical professionals reduce claim denials by more than 70% and increase their revenue significantly.
FAQs
What do urgent care billing services include?
The immediate care center billing includes end-to-end billing of patients, medical coding, insurance eligibility verification, prior authorization, etc. Additionally, our revenue cycle team submits claims to payers on time and recovers aging A/Rs to support your practice.
Why do urgent care centers face unique billing challenges?
Walk-in urgent care medical clinic faces numerous challenges, like:
- Administrative burden on the in-house billing team
- Diverse payer mix increasing complexities
- Atypical diagnostic codes
- Walk-in patients lead to lengthy eligibility checks
- Frequent claim denials, rejections
How can outsourcing urgent care billing improve revenue?
Outsourcing is the most economical way of managing your practice’s revenue cycle management. It allows providers to hire a trained and skilled RCM team without sacrificing a big chunk of their earnings on training, retaining, benefits, etc. Additionally, practices can improve their patient care and satisfaction through delegating staff to specific billing and coding tasks and reducing the burden on their in-house staff.
