What CPT Codes are Used in an Urgent Care Practice?

Urgent care centers provide access to healthcare for patients with an urgent medical condition that is not considered life-threatening, but still needs immediate treatment as it has the potential to progress into such a threat if treatment is not provided within 24 hours. Such non-life-threatening injuries or illnesses include sprains and minor burns. While urgent care centers are not a substitute for primary care, they are a convenient option that patients can access during the day, at night, on weekends and most holidays. Urgent care medicine has developed into a separate specialty that requires a distinct knowledge base, skill set, and experience. Urgent care specialists need to submit claims with specific codes pertaining to this specialty. They can rely on medical billing companies to submit error-free claims for accurate and timely reimbursement.

According to Medical Economics, urgent care centers are growing rapidly. The number of clinics increased from 6946 in 2015 to 8285 in 2018 showcasing the growing demand of UCC. According to the Urgent Care Association (UCA), UCC handles about 89 million patient visits every year and more than 29 percent are primary care visits. Providers need to stay up to date on coding changes and billing guidelines to get reimbursed properly and thrive as they meet patient demand.

The CPT codes for urgent care fall in categories 99202-99215, Office or Other Outpatient Services:

Codes 99202-99205 New Patient Office or Other Outpatient Services

Codes 99211-99215 Established Patient Office or Other Outpatient Services

99202 New Patient Office or Other Outpatient Services, 15 – 29 minutes Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making.

99203 New patient office visit or Other Outpatient Services, 30-44 minutes Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity.

99204 New patient office visit or Other Outpatient Services, 45-59 minutes Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and Medical decision making of moderate complexity.

99205 New Patient Office or Other Outpatient Services, 60 – 74 minutes Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity.

99212 Established patient office visit, 10-19 minutes Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.

99213 Established patient office visit, 20-29 minutes Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.

99214 Established patient office or other outpatient visit, 30-39 minutes Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.

99215 Established Patient Office or Other Outpatient Services, 40 – 54 minutes Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity.

There are also two main ‘S’ code categories that are exclusive to urgent care:

Code S9083: This is case rate code global fee urgent care centers. It is used by some payers to bundle all services rendered in an urgent care visit into a single, one-size-fits-all global code for reimbursement with the same single flat-rate fee.

Code S9088, “Services provided in an urgent care center (list in addition to code for service)”
These S codes:

• Can be billed for every visit in an urgent care center with an E/M code, with the exception of Medicare.
• Are add-on codes and cannot be billed alone.

Changes in CPT codes relevant to Urgent Care

The Centers for Medicare & Medicaid Services (CMS) issues new updates every year that can make a huge impact on claim submission. Urgent care centers should stay updated on changes made to codes and payer rules and regulations to submit accurate claims. For instances, several changes were made to Evaluation and Management Codes in 2021:

• History and exam are not used to select an E&M service, but still must be performed in order to report CPT codes 99202-99215.
• E&M code selection is based on either 1) The level of medical decision making (MDM) OR 2) The time performing the service on the day of the encounter
• The definition of time associated with CPT codes 99202-99215 was changed from the typical face-to-face time to total time spent on the day of the encounter.
• The medical decision-making elements associated with codes 99202-99215 now consist of three components: 1) The number and complexity of problems addressed 2) Amount and/or complexity of data to be reviewed and analyzed, and 3) Risk of complications and or morbidity or mortality of patient management. Two of the three elements must be met or exceeded to select a level of E&M service.

The significant changes in urgent care coding for 2022 are the addition of codes and modifiers relating to the COVID vaccine.
The CPT codes for this service frame based on:
– Administration of intramuscular or subcutaneous injection (vaccine)
– Management of vaccination complications

In addition, for reporting these services, you have to use modifiers such as:

– RT- Right Side
– LT- Left Side
– VFC- Vaccines for Children program patients only

In addition to the introduction of new codes and modifiers, changes were made to the HCPCS Level II code set.

Challenges of Medical Billing and Coding in Urgent Care

Urgent care centers many challenges in terms of billing and coding:

• Coding: Urgent care has almost similar coding guidelines as primary care. Providers must assign the code that is appropriate for the medical service rendered and also comply with insurance company rules.
• Limited time: In urgent care, providers do not have time for insurance preauthorization and verification before providing the service.
• Limitations of Medicare: Although Medicare covers 80% of the urgent care costs, this coverage is lower than private insurance in the case of urgent care reimbursement.

In the face of these challenges, outsourcing medical billing to an expert is a practical option for urgent care. As physicians and their staff focus on delivering urgent care, partnering with an experienced medical billing and coding company can ensure accurate and timely claim submission for optimal reimbursement.

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Loralee Kapp

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI. She is CPC certified by the American Academy of Professional Coders (AAPC).

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