Urgent care billing – Comprehensive Medicare Guidelines 2024

As per the critical requirement initiated by the healthcare regulatory bodies in the USA, medical providers, and healthcare practitioners would only get reimbursement for their services if they follow a value-based healthcare model in their practice revenue cycle management — a patient-centric approach in providing healthcare services to their patients. As per the insurance compliance requirements regarding the fee-for-service, your practice is financially dependent on the healthcare outcomes, including improving the patient’s health and minimizing the effects and incidence of chronic disease against the cost of delivering the outcomes. No matter how much volume of patients you serve in your organization, minimum negligence regarding value-based reimbursement in your urgent care billing workflow processes would make you a victim of Federal compliance and thus overwhelm your practice under legislative penalties.

outsource medical billing to a renowned healthcare administrative partner will remain beneficial as it overcomes most of the legislative complications of the processes.

Having said that, Introducing MedsIT Nexus, your trusted USA-based group of urgent care billing specialists whose certified professionals are excel in handling crucial insurance collection cases, with a specific focus on common urgent care procedures. Our comprehensive and tailored solutions for healthcare providers, ensures accuracy and compliance in every aspect of the billing process. Led by a dedicated RCM solution manager, our team stays ahead with the latest updates, particularly the CMS/AMA general E&M Coding guidelines, providing insightful guidance for accurate urgent care claims filing. Choosing MedsIT Nexus for efficient, compliant, and expert urgent care billing services would be highly beneficial as we prioritize your success by navigating the complexities of insurance claims, allowing you to concentrate on delivering quality patient care with confidence. In this particular guide our experts aim to provide almost every possible query most commonly asked by our clients – urgent care providers. Therefore, following it will definitely help you find the solutions for everyday scenarios that take place in the immediate care billing departments.

Enhancing Urgent Care Revenue Cycle Management: Streamlining Insurance Collection Workflow with MedsIT Nexus

Before we move forward to the urgent care coding guidelines, here is an overview of our RCM; it is critical to know that your practice must adopt a healthy practice revenue management to get maximum reimbursement from your Payor with minimum denials. We at MedsIT Nexus serve our clients with scalable provider enrollment & credentialing services tailored to the urgent care specialty within RCM, which is the backbone of the process. The process starts right from appointment scheduling and continues with patient registration, EOB validation, coding and billing, claim submission, adjudication, and denial process and ends on the final step, which is patient billing and collection. Our process strictly adheres to urgent care compliance, ensuring that our contracted practice experiences a maximum cash flow for its rendered services. Follow the official infographic mentioned below for a better understanding of the Credentialing enrollment and RCM process.

Comprehensive Guide to CMS/AMA Urgent Care Billing: Decoding Pos-20 & E/M CPT Codes for Optimal Reimbursement

As dictated by the CMS/AMA formal coding regulations, it is imperative that urgent care claims processed post-June 1, 2022, adhere to billing specifications, utilizing POS 20 with a corresponding level of service provided to the member. This specific code has evolved into a pivotal requirement for successfully filing a claim with the Payor through Medicare because of the reason medical practitioners strategically employ S codes to maximize billing for their services, particularly after regular treatment hours when the costs associated with rendered services are heightened.

POS 20 is a place of service code that is used to indicate that the patient is treated or diagnosed for the illness or injury for unscheduled ambulatory patients that were seeking immediate medical attention within urgent care facility rather than emergency room more precisely. However, the claims are still processed with the codes POS-10 or POS-11 where the location is still a primary care office that is distinct to the hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF) where the medical providers perform their routine services health examinations, diagnosis, and treatment of disease or injury on a ambulatory basis. In the given context, it is critical to understand that Medicare will reimburse for the urgent care provided services while it might raise the objection on the claims that consist of the naturally expensive walk-in procedures; if so – to increase practices revenue medical providers are required to maximise the amount of privately insured patients.

Most commonly used urgent care codes — CPT & HCPCS codes

There is a significant similarity between the medical procedures and conditions in the primary care office and the urgent care facility. Urgent care and primary care services are correlated; therefore, the medical insurance legislative consultants recommend creating an identical entity to avoid anti-kickback laws such as a Stark law, which governs medical providers for the Medicare patient's referrals for services that benefit them financially.

In this context, “S codes” must be used as per the CMS billing guidelines, identifying the type and level of service provided to the patients in urgent care settings with an indication that the visit is worth extra compensation over the primary care visits. Moreover, the providers are also required to bill the urgent care services under a separate taxpayer identification number to keep them distinct from the primary care services.

S codes are the critical component of the Healthcare Common Procedure Coding System (HCPCS) in Urgent Care billing where these codes are billed along with relevant Evaluation and Management CPT codes (99201 - 99215) from the CPT manual's office or other outpatient services section. This integration ensures comprehensive documentation and accurate billing practices, optimizing reimbursement for urgent care services.

Along with it, appropriate modifiers are also required to add with codes for any procedures performed during the visit. There are two commonly used S codes, S9088 and S9083, in the urgent care facility, and here in this section, we are going to cover the broad aspect of this particular coding system, such as the reimbursement, procedure code medicare description and CMS billing guidelines, so on and forth.

Exclusive “S” Codes for Urgent Care Billing Departments — Comprehensive difference between S9083 & S9088

Medical billing codes that are specific to the urgent care centers begin with the letter “S”. This is an identifier that these codes are not billable to government Payors such as Medicaid & Medicare instead, private insurers and agencies (including managed care organizations [MCOs] and state workers compensation boards) might pay for them – using these codes helpful in defining specific services that are neither recognized nor reimbursed by Medicare or Medicaid. This is because Medicare has no special rules for urgent care and is considered equal to any other outpatient physician office.

Also, there are other than mentioned “S” billing codes, such as 99050 and 99053, which are for urgent-care patient visits outside office hours, and 99051 is for providing extended hours services such as on evenings, weekends, and holidays — including Christmas and New Year's Day. Here, we would solely focus on discussing the commonly used S9083 and S9088 code descriptions, the reimbursement, the core difference, and the conceptual gap between them.

When billing with an S9083, the reimbursement by the Payors would be based on a flat rate methodology – a global fee for service that allows urgent care to combine the services and other procedures performed on the same day in an urgent care center without distinguishing between the procedures of a hangnail or a heart attack. Conversely, when the claim is filed with the S9088, the insurer uses this particular code to identify the services rendered within the urgent care center instead of the traditional primary care physician offices — which significantly cost more because of the unscheduled walk-in visits during all open hours and offering significantly extended hours, which may include evenings, weekends, and holidays. Thus, this particular code is used as an “add-on” code to reimburse the urgent care centers with the increased cost of rendering service

2024 Updated Urgent Care Evaluation & Management CPT Codes

As per the health insurer legislative regulations, such as CMS, services rendered in urgent care centers must be billed based on the level of service provided to the member, which is determined by reporting applicable evaluation and management (E&M) codes.

These E/M CPT codes are broadly categorized into the NewPatient & EstablishedPatient CPT codes. Claims submitted for these office visit code family are analyzed against the following information mentioned below in an Urgent Care Comparative Billing Report (CBR) — it is one of the many other tools used in billing and coding audits for the primary purpose of assisting individual providers to become proactive in addressing potential billing issues and performing internal audits ensuring compliance with Medicare guidelines

Note:
The Centers for Medicare and Medicaid Services sought clarifications on the reporting of evaluation and management (E/M) services, prompting revisions to the CPT 2024 code set. These revisions include the removal of time ranges from office or other outpatient visit codes (99202-99205, 99212-99215) and alignment of the format with other E/M codes

Outsource your Urgent Care Billing needs to MedsIT Nexus – 10 X cost efficiency of your revenue cycle process with our automation

Outsourcing and automation are the two concepts that are strategically connected to the efficiency of your urgent care revenue cycle processes. The multistep processes and the required software licensing and other expenses resulting in the high cost of collection for the small practices, which is a critical KPI that urgent care facilities use to track the expenses that are involved in their patient financial services.

These expenses may include the patient billing, including employee wages, office facility overhead, and even the cost of paper for invoices, and it must be optimized for a healthy and more efficient revenue cycle, which means the cost must be maintained at the lowest threshold in a complete cycle which results in the healthier margins and better financial performance. Finding ways to lower this particular cost is an ongoing challenge, and this is where the MedsIT Nexus revenue cycle outsourcing comes into play that automates the processes by using urgent care EHR technology and a dedicated, proficient workforce to handle the repetitive and time-consuming tasks, significantly cutting down the cost of production and boost efficiency in your patient care delivery that assists your practice in adopting the value-based reimbursement model ultimately boost practice’s revenue with the optimized insurance collection rate.