Managing Coding Challenges in Urgent Care Billing

Introduction to Urgent Care Coding

Medical codes used on Urgent Care billing carry the same kind of challenges as other kinds of billing. They are directly linked to the amount that will be reimbursed by the Insurance. If the right codes are used, the applicant can expect to receive full reimbursement for the services rendered. If the codes are wrong, a provider can end up collecting less than the actual cost, and in some cases, have the claim rejected outright.

Typically, services provided at an Urgent Care facility are coded according to the level of services rendered by physicians to patients who visit a regular physician’s office. In other words, the codes range between CPT 99201 to 99215.

Understanding Reimbursement Caveats

It is important to remember that most reimbursements would be based on a flat rate method that combines the services and other procedures performed on the same day. However, some carriers reimburse on the basis of the level of services rendered. These are usually categorized in three parts. CPTs 99201-99202 & 99211-99212 are categorized as Level 1. CPTs 99203 & 99213 are categorized as Level 2 services and they will attract a higher reimbursement rate than Level 1. CPTs 99204-99205 & 99214-99215, which command greater reimbursements than Level 1 and Level 2, are categorized as Level 3 services.

From the perspective of the nature of services provided, the categorization may be described as:

1. Level I / Triage care (Minor Problems): Comprises only evaluation and management services, with no diagnostic tests
2. Level II / Intermediate care (Moderate): If injections, vaccines or splinting are administered along with Level I services
3. Level III / Complex care (Severe): Includes IV infusion, sutures, along with Level I services
   Overcoming Coding Challenges

One needs to bear in mind that Urgent Care billing, if one attempts to do it in the best possible manner with accurate coding, timely submission and diligent follow-ups, can take up plenty of time and effort. Given the high wages of skilled coders and billers, coupled with rising operational costs, maintaining an in-house staff is an expensive affair nowadays. Then, there is the need for constant training for, and upgrading one’s knowledge of, continually changing coding norms and regulations.

To manage such challenges, many Urgent Care facilities are choosing to outsource all their billing and coding requirements to professional, dedicated third-party specialist organizations. With such an Urgent Care billing partner, all their billing needs are taken care of at a fraction of the usual cost, along with improved efficiency and increased productivity. Till domestic costs come down, strategic outsourcing to offshore billing companies might just be the best solution for Urgent Care businesses to cut operational expenses, improve collections and stay profitable.