Urgent Care Billing: A Comprehensive Guide & Reasons to Outsource
Your urgent care practice is thriving – you have decent patient volume, you have positive reviews online, and you hire providers dedicated to providing evidence-based, compassionate care – but your profit margins are still not what you expected. If your revenue leaves something to be desired, your billing processes could be the issue. Learn the basics of urgent care billing and how you can boost your practice revenue with just a few tweaks.
How Does the Urgent Care Billing Process Work?
As the gap between the primary care provider and the emergency room, urgent care clinics play a vital role in our healthcare system. That’s probably why they’re increasing in popularity and are expected to be worth $26 billion by 2023. To command your fair share of the market, you have to understand the basics of billing and how you can optimize your workflows for maximum returns.
Urgent Care Billing Starts at the Front Desk
Urgent Care billing is a cycle – and that cycle begins at the front door. By making good financial policies that begin at check-in, you can increase your revenues and spend less money on costly collection processes.
Urgent care clinics generally do not have a pre-registration process, due to the walk-in nature of appointments. However, the receptionist or front desk person must take basic information for billing purposes when a patient initiates an appointment.
Essential information includes:
- Basic demographic information such as name, address, birth date, and the reason for the visit.
- Name of insurance company, primary care provider, and policy number.
Ideally, information during the registration process will facilitate the creation of an electronic health record (EHR). Providers and support staff will work collaboratively within the EHR to make patient notes, record health history, treatment recommendations, and more. An up-to-date patient record with thorough notes makes the billing process much more streamlined. If a patient is a repeat visitor, it is important to make note of any patient demographic or insurance information at every visit.
Confirm Financial Responsibility
An urgent care clinic does not always have the time to call insurance companies to obtain pre-authorization for services. Patients should be familiar with their plan information and know what kinds of costs they can expect to incur from a walk-in facility. To avoid potential billing issues, it is important for each patient to sign an affidavit of financial responsibility prior to receiving medical services.
Post-Visit Follow Up
As a patient receives services from a physician or other provider, they should record all procedures and relevant information in the EHR. This helps create an accurate bill to facilitate in the creation of the claim and the collection of the patient balance.
Transmitting the Claim
The final part of the billing process, after each medical procedure has been properly coded and checked for regulatory compliance, is to send it out to the payer. The bill that the insurance company receives includes essential information about the diagnosis, procedures, and associated charges. An accurate bill helps ensure a streamlined reimbursement process, which helps ensure that you, as the healthcare provider, get reimbursed in a timely fashion.
Most healthcare practices submit their claims electronically, as this is the most accurate and expedient way to get reimbursed. Generally, medical software aids in the recording of patient information and the creation of claims for reimbursement.
Urgent Care Billing and Medicare
In general, urgent cares can bill more for their services using S codes, recognizing that after hours treatment costs more. CMS, however, may be less likely to pay for urgent care services, and errors in billing can only delay the process of reimbursement. Medicare uses a special facility code for urgent care centers (POS-20), but it still processes claims as if it were a primary care office (i.e., using codes POS-10 or POS-11). Medicare will reimburse urgent care for services rendered, but it’s important to note that it may not reimburse facilities for the naturally higher costs of providing walk-in care. As such, health care providers who wish to increase practice revenue should maximize the amount of patients who are privately insured.
The Cost of Urgent Care Billing
You have two main options when it comes to handling your urgent care billing: hiring in-house coders and billers or outsourcing the process to a professional. Both will require software licenses and other expenses. While some like having full control over the billing process, having in-house billers and coders tends to be more costly. You will have to pay salary and benefits to in-house employees, and an absence or unexpected employment termination can seriously affect your process.
Why Outsource Your Billing?
Appropriate, cost-efficient processes play a vital role in your practice revenue cycle. Outsourcing can help boost revenue and optimize resources:
- An outsourced billing company can help you with year-round billing needs, without having to account for unexpected employee downtime. This also allows your staff more time to engage in more patient care activities.
- Billing agencies are generally better at collecting delinquencies compared to in-house staff.
- Save money on hardware and software costs in your office.
- Convenience is one of the main reasons that urgent cares choose to outsource. A billing provider handles all the data entries, fixes rejected claims, and sends invoices to the patient. Data transfer is seamless with the help of an EHR interoperability system.
- Allow your staff to focus on patient-care activities, including delivering compassionate, evidence-based care that gets more patients in through your doors.
- Outsourcing will reduce the risk of billing and coding errors, which serves two purposes: first, it makes for a more streamlined billing process and more collections. Second, it helps ensure that your practice remains in compliance with regulatory agencies, like the Office of the Inspector General and the Centers for Medicare and Medicaid Services (CMS). The costs of noncompliance, even if accidental, can have an effect on your revenue cycle management.
Urgent Care Billing Guidelines
Urgent care providers evaluate and treat many of the same conditions as a primary care office. As such, the billing process is very similar. However, there are certain urgent care-specific codes – beginning with an “S” – that differ from primary care codes.
S Codes are Healthcare Common Procedure Coding System (HCPCS) codes that were originally designated by BCBS, but now many other payors accept them. They are only used by urgent cares, and some payors require them to reimburse facilities for services rendered.
Urgent cares have two main options when coding and billing for services rendered:
S9088 or “services provided in an urgent care center (list in addition to code for service)” allows for urgent cares to bill for the evaluation and treatment of medical conditions, while recognizing that services in an urgent care carry an inherently higher price tag. The S9088 code does not stand alone; it must be billed with an appropriate evaluation and management (E/M) code. The S9088 code allows urgent cares to receive reimbursement for at least a portion of the increased cost of providing immediate care.
S9083 – allows urgent care to charge a global fee for service, regardless of what treatment the patient receives. In some cases, a managed care organization (MCO) will require a facility to bill under code S9083. In fact, MCOs in some states – such as Florida and Arizona – require that urgent cares bill all services under S9083.
In general, it’s best to avoid the S9083 code if it’s possible.
The reason is simple: based on a global fee-for-service scale, your urgent care will be reimbursed the same amount for packing a nosebleed as it would managing a heart attack.
These two codes account for virtually all urgent care visits, (S9083 by itself, and S9088 with appropriate add-on CPT E/M codes). There are a couple of other S codes that may be appropriate for urgent care practices, but virtually all encounters can fall under these two categories, with the exception of Medicare. Medicare codes are separate, and the rate of reimbursement depends on geographic location and established medical necessity, among other factors.
Before a bill can go to a patient or payer, it must satisfy certain regulatory requirements, including compliance with HIPAA and the Office of the Inspector General. A biller must also ensure that each charge is, in fact, billable, according to the payer’s rules. Denied claims can be time-consuming, waste resources and manpower, and further complicate the billing process.
Coding Guidelines for Urgent Care Billing
Once a patient encounter is complete, a coder typically translates all the diagnoses and procedures into medical code sets universally used by the medical industry (i.e., ICD 10, CPT). ICD-10 codes provide a diagnosis, while current procedural terminology (CPT) codes designate any procedures that a provider used in the process of delivering care. CPT codes are used in conjunction with an ICD (diagnosis) code for the purposes of creating patient bills. CPT codes come in one of three categories:
- Category 1 CPT codes are the most popular, and they encompass the evaluation and management of disease, surgery, radiology, pathology and laboratory testing, medicine, and anesthesiology.
- Category 2 codes are supplemental, quality assurance codes that are optional and not a replacement for Category 1 codes.
- Category 3 codes are for emerging procedures and technology that may not be approved by the FDA.
Generally speaking, an urgent care would only have occasion to bill Category 1 CPT codes.
The Most Common CPT Codes in Urgent Cares
The majority of CPT codes used in urgent cares are E/M codes. In an urgent care setting, some of the most common CPT codes include:
99214, according to the AMA, is for an “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 detailed history, a detailed examination and medical decision making of moderate complexity.”
99213 is for an existing patient that requires treatment, but does not have the same level of complexity as 99214. It is one of the most commonly billed codes, because it is easier to fulfill the criteria for reimbursement. However, it does not typically reimburse as much as a 99214.
99204 is one of the most commonly used codes in an urgent care setting for new patients. It requires fulfillment of three key criteria: a comprehensive history, comprehensive exam, and medical decision-making of moderate complexity. It has a relatively high rate of reimbursement at a comparable low risk of noncompliance.
According to CPT assistant, which provides industry-recognized guidance to billers and coders, most urgent care CPT codes fall under 99202- 99205 and 99211-99215. Remember, since urgent cares serve as the gap between a primary care office and an emergency room, you cannot bill with ER-designated CPT codes, as this could serve as a compliance risk.
Urgent Care billing is complicated but tends to follow similar procedures as a primary care office. You must follow coding and billing guidelines to remain compliant with regulatory requirements. Hiccups in the billing process can upset your revenue cycle management and affect your practices bottom line. Outsourcing is an effective measure for streamlining billing, eliminating redundancies, and improving your collections while allowing your employees to focus on patient-centered care.
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