Urgent Care Billing Guidelines

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Couple making a payment at an urgent care center.
Couple making a payment at an urgent care center. (Image: AndreyPopov/iStock/Getty Images)

Urgent care centers, even at the most sophisticated facilities, provide many services that are paid for under primary-care billing codes. Thus, urgent care billing is much like billing for primary care, but there are a few important differences: Providers are all but required to bill urgent care services under a separate taxpayer identification number if they also provide primary care services. There are other distinctions as well.

Procedure and Disease Codes

Urgent care uses the same standard codes as any other type of medical care billing -- a combination of Current Procedural Terminology and International Classification of Diseases codes, better known as CPT and ICD codes. The two codes specify the treatment by the health provider and what the treatment was for. With some payers, notably Medicare, additional codes fine-tune the dollar value of the treatment based on the location of service: Geographic codes factor in the regional cost of living and place-of-service codes specify the type of facility, be it a doctor's office, an urgent care center or a hospital.

Taxpayer ID Number

If a medical provider adds urgent care services to primary care services or vice versa, consultants recommend creating separate entities to avoid violating anti-kickback laws -- such as the Stark law, which governs physician referrals for Medicare patients. Besides, setting up separate businesses, even within the same facility, forestalls patient complaints. For example, suppose the patient pays a high urgent care co-payment but his deductible is only credited for a modest primary care co-payment? It can happen if the billing code is identical to a primary care code. The result is an angry patient and a headache for the billing department.

S Codes Add Money

Codes that begin with the letter S are specific to urgent care, and the S means that private insurers may pay for them but Medicare does not. The S9083 code is insurers' shorthand for payment by flat fee, S9050 and S9053 are for urgent-care patient visits outside office hours, and S9051 is for urgent care performed during regular office hours. The S codes are added on to the rest of the billing codes to indicate that the visit is worth extra compensation over primary care visits. However, not all private insurers automatically pay for S-coded services.

Medicare Says Meh

While urgent care is much cheaper than a visit to the hospital emergency room, Medicare is a wet blanket when it comes to paying more if the care can take place outside a hospital. Although Medicare uses a special facility code for urgent care centers (the code POS-20), it still treats urgent care as if it's a primary-care location (under code POS-10 or POS-11). In short, health care providers who want their urgent care services to boost revenues should look to treating patients who are privately insured; insurers not only pay a bit more, but the provider benefits from high co-payments.

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