Urgent Care vs. Emergency Room Billing: Key Differences

With the revenue cycle industry evolving quickly in healthcare billing, CMS mandates each healthcare facility to establish its own organization's billing guidelines, which must be designed to relate the intensity of healthcare services to various levels of efforts, particularly in two different organizations named urgent care centers, and emergency department billing. The continued fall of the ER reimbursement ratio is a sign of a distorted billing process. Today's dynamic billing and coding guidelines highly demand urgent care centers and emergency departments, their ancillary staff, RCM practitioners, and decision-makers to stay compliant with billing policies of both types because both healthcare organizations differ regarding the kind of services rendered and their billing and coding process. Understanding the difference between urgent care and emergency department billing is not straightforward, and only experienced and well-versed implement accurate billing processes for each type because many believe that there is slight/no difference between the billing and coding guidelines of both. In this regard, employing the services of professionals and certified billers to comprehend the two different billing approaches will ease the task. Considering MedsIT Nexus as your 1st choice for outsourcing urgent care and ER billing will result in tremendous results.

Navigating the Differences of Urgent Care and the Emergency Room

Urgent care billing

To help you avoid surprise billing, it is essential to tell about the conditions billed as urgent care services; look into these conditions to know when you should visit an urgent care facility. Urgent care billing mainly incorporates billing for services rendered for conditions that are not considered emergency, such as fevers, flu or cold symptoms, ear infections, animal or insect bites, seasonal allergies, bronchitis, sprains and broken bones, cuts and bleeding that may require stitches, vomiting or diarrhea, breathing discomfort, such as moderate asthma, urinary tract infections, x-rays and lab tests, abdominal pain, and minor back pain.

CMS-1500 Claim form

CMS-1500 claim form: Place of service-20 (POS-20)
There are two specific reasons to use the CMS-1500 form.

1. CMS-1500 is a standardized medical claim form that individual healthcare providers (therapists, physicians) use to submit billing information and is thus used in urgent care billing.
2. This form is used if you submit a claim for services outside an institutional setting, such as outpatient procedures, office visits, or lab tests.

Coding Guidelines

For appropriate coding, urgent care facilities use CPT codes (99213, 99214, 99204) concerning new and established patients and time spent on the encounter day; another type is S codes (S9083 & S9088). The E/M codes are selected based on the medical decision-making (MDM) level and the time rendering the services on the encounter day, with particular consideration on the definition of time for CPT codes, which has been from face-to-face time to total time spent on encounter day.

CPT codes	Type of patient	Requirements
E/M code 99204	For new patients	Must fulfill 2/3 components: Comprehensive history Comprehensive exam Moderate complexity MDM
E/M code 99213	For existing patient
E/M code 99214	For established patient	Must fulfill 2/3 components: Detailed history Detailed examination Moderate complexity MDM

Urgent care organizations also use S codes such as S9088 for "services rendered in an urgent care (list in addition to code for service)." In contrast, S9083 is mainly used by Managed Care Organizations (MCO) due to its single service fee system in conjunction with the E/M code.

Documentation requirements

Urgent care providers should follow the documentation's best practices in order to ensure compliance with updated guidelines. They must document the patient's chief complaint, detailed history of current illness, and thorough documentation of the exam findings. Moreover, diagnostic tests & results, and treatment plans are also documented.

In-network/out-of-network consideration

In most urgent care cases, it is asked to stay in the network. Preferred provider organization (PPO) plans permit to get out-of-network services, but the cost will be higher. Comparatively, other plans such as exclusive provider organization (EPO) and health maintenance organization (HMO) do not permit out-of-network services.

Cost of urgent care visit

If you compare urgent care bills with ER bills, you will notice that urgent care centers are less expensive. An urgent care bill is average from $100 to $200. According to the latest update of 2024, the bill for urgent care service without insurance may range from $80 to $280 for level 1 and $140 to $440 for level 2. The reason for lower urgent care bills compared to ED is that urgent care centers have fixed hours and a list of problems treated. The President of the American Academy of Urgent Care Medicine estimated that around 70% of patients use insurance cards at urgent care. Hence, they have to pay only a minimum amount (copay).

Reimbursement considerations

For the S9083 code, most insurance companies use a Flat fee (global fee) system, also called the case-rate system, a payment method/structure in which urgent care providers receive flat (fixed/same) payment for every patient visit, regardless of the services rendered.
Code S9088 allows urgent care centers to get reimbursement for a portion of increased cost for rendering immediate care ranging from no reimbursement up to $100.

Medicare coverage

S9083 & S9088 pertain to all urgent care services for billing except for Medicare, which means that S codes are not billed to Medicare.
In addition, as services gained from urgent care fall under outpatient care, Medicare Part B usually covers 80% of the eligible cost of urgent care treatment to treat sudden injury or illness.

Emergency room billing

Emergency room billing will mainly comprise billing of conditions that require emergency treatments, such as severe chest pain, severe abdominal pain, wheezing or shortness of breath, paralysis, intestinal bleeding, high fevers or rash, especially among children, vaginal bleeding with pregnancy, repeated vomiting, poisoning, severe head or eye injuries, heart attack allergic reactions and unconsciousness. The level of billing details for emergency room visits depends upon ED disposition and payer type.

UB-04 & CMS-1500 Claim form

CMS-1500 claim form:

• Place of service (POS): POS-23 – professional claims (ED visit E/M codes are restricted to emergency place of service)

UB04 claim form:

• Revenue code: 0450 – emergency room (general)

ED billing also uses the UB-04 claim form along with CMS-1500 because the UB04 form is used by institutional healthcare providers such as rehabilitation centers, hospitals, and nursing homes. Another reason to use the UB-04 claim form is that it is used whenever submitting claims for services within an institutional setting, for instance, inpatient hospital stay or outpatient surgery.

Coding Guidelines

Emergency department E/M CPT codes ranging from 99281-99285, established by AAPC, are employed to bill emergency department services. These codes are implemented depending on five levels of MDM, regardless of new or established patients, and are reported per day. Furthermore, AMA declares time as a non-descriptive component for E/M because these services are rendered on a variable intensity basis that involves multiple encounters with multiple patients over an extended time.

E/M or CPT code	Level of Medical Decision Making (MDM)	Requirements (3 components)	Clinical example
99281	Straightforward MDM	Problem-focused history Problem-focused examination Straightforward decision making	Insect bite (uncomplicated)
99282	Low complexity MDM	Expanded problem-focused history Expanded problem-focused examination MDM of low complexity	Localized lesions, skin rashes, sunburn
99283	Moderate complexity MDM	Expanded problem-focused history Expanded problem-focused examination MDM of moderate complexity	Mild asthma that does not require oxygen
99284	Moderate complexity MDM	Detailed history Comprehensive examination MDM of moderate complexity	Chest pain; stable & asymptomatic
99285	High complexity MDM	Comprehensive history Comprehensive examination MDM of high complexity	Chest pain; unstable and acute MI

You are supposed to bill the level of service depending upon interventions in which facility codes will indicate the intensity and volume of resources that the facility uses to provide care; meanwhile, professional codes denote the work performed and the complexity. Documentation and medical records that support the emergency department E/M codes might be required to support the given level of care.
`1CMS emergency department coding guidelines suggest that facility coding guidelines should be established on hospital facility resources and not on physician resources and should follow the intent of CPT code descriptor in which guidelines should relate the intensity of hospital resources to various levels of efforts that the code represents without facilitating upcoding. Moreover, CMS has not uploaded any particular national E/M guidelines for ED, requiring providers to create their own rules and criteria for each ED visit.

Documentation requirements

The previous requirement of documenting a physical examination and a complete history is not enough; a medically appropriate history and physical examination are required, making medical decision-making (MDM) a sole factor and requirement.

In-network/out-of-network consideration

Emergency care is not restricted to just in-network providers; if out-of-network providers give emergency service, the coinsurance rate and copayment must match in-network provider rates. The Affordable Care Act (ACA) asks insurers to cover out-of-network emergency services the same way in-network emergency care is covered, showing that the deductibles will be the same for both.

Cost of ER visit

ED service costs $12,00 to $13,00, much higher than urgent care visits. Depending upon the level of care, the ER visit bill is $623 in Maryland and $3,102 in Florida, and the cost may vary by region, too.
Why do ER visits have inflated bills? Emergency departments are equipped 24/7 with physicians, physician assistants, nurse practitioners, and trained nurses. These departments also have diagnostic and laboratory services and access to specialists; these resources generate higher operating overhead costs, transferring this cost to patients and insurers.

Reimbursement considerations

Payment cuts in Medicare and Medicaid and strict restrictions from insurers have put emergency departments under financial pressure and reduced revenue growth. ER visits are not paid if emergency department services are provided on the same day as the nursing facility assessment. CMS clearly states that as long as the facility is following its own system, which relates the intensity of facility resources to different levels of HCPCS codes, and as long as given services are medically necessary and documented, it will be considered compliant to implement department visit code to be billed and will be reimbursed. Most Medicaid and Medicare programs reimburse using the fixed fee-based system for both inpatient and outpatient visits, and in general, emergency care providers are compensated on a fee-for-service basis in which each service is aligned with the CPT code and results in Medicare reimbursement, but only the medically necessary portion of a face-to-face visit is permitted by Medicare for code 99285.

Medicare & emergency room billing

Under the Affordable Care Act (ACA), health insurance policies and plans are supposed to cover emergency room services, indicating that regardless of health plan, health insurance, Medicare, or Medicaid, the insurance plan must cover ED services, and the coverage will be provided after pre-authorization. Medicare Part B and Medicare Part C (Medicare Advantage plan) mainly cover 80% of medically necessary ED services cost, and the rest of the 20% of the price is considered deductible or coinsurance; however, the patient has been admitted to the same hospital for a similar condition within three days of ER visit, a copayment will not be paid by the patient as it would be regarded as a part of inpatient stay.

MedsIT Nexus: Your companion in professional billing

Are you perplexed by the differences between urgent care and emergency department billing? Is this confusion leading to errors in your administrative tasks and overburdening you? The solution is MedsIT Nexus because it has certified emergency department coders and billers, along with certified coders and billers for urgent care. Our billing personnel have in-depth knowledge of professional billing for both organizations, paving a path to success and reimbursement. We have a lot of happy clients because we are known for our experience and quality. Shaking hands with MedsIT means increasing reimbursement and streamlining RCM.