Urgent care billing and urgent care coding are going through a period of change, and revenue cycle leaders at multiple types of provider organizations will need to pay attention. From new codes, to the impact of COVID-19 and the No Surprises Act, you’ll need to adjust your urgent care billing services to keep up and make sure you’re keeping your cash flows healthy. Let’s take a look at what’s going on in the world of urgent care billing.
ICD-10 Updates for Urgent Care Coding
We’re rolling up on the newest set of ICD-10 updates for 2023, but it’s worth making sure you’re clear on urgent care coding changes from earlier in the year before you move into the next round. The Centers for Medicare and Medicaid Services (CMS) released 159 new codes, deleted 32 codes and revised 20 codes for FY 2022. Here are some of the most common and impactful for urgent care .
Codes for polyuria, low back pain, and cough now require an extra digit for specificity.
- Nocturnal polyuria (R35.81)
- Other polyuria (R35.89)
Low back pain:
- Low back pain, unspecified (M54.50)
- Vertebrogenic low back pain (M54.51)
- Other low back pain (M54.59)
- Acute cough (R05.1)
- Subacute cough (R05.2)
- Chronic cough (R05.3)
- Cough syncope (R05.4)
- Other specified cough (R05.8)
- Cough, unspecified (R05.9)
Additionally, social determinants of health (SDoH) should be kept in mind. SDoH are “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes” according to the Centers for Disease Control (CDC) . From a coding perspective, they can impact the level of risk you use in determining the best evaluation and management (E/M) codes. Some examples include food or housing insecurity, but they can extend into whether or not a patient can afford their medications or properly understand the directions a provider is giving them. These are some of the new diagnosis codes:
- Depression, unspecified (F32.A)
- Irritant contact dermatitis (L24.A0 – L24.B3)
- Nonsuicidal self-harm (R45.88)
- Personal history of self-harm (Z91.51)
- Personal history of nonsuicidal self-harm (Z91.52)
- Feeding difficulties, unspecified (R63.30)
- Pediatric feeding disorder, acute (R63.31)
- Pediatric feeding disorder, chronic (R63.32)
- Abnormal findings of blood amino-acid level (R79.83)
- Encounter for immunization safety counseling (Z71.85)
COVID-19, of course, also has an impact on urgent care billing and coding. Code U09.9 (Post COVID-19 condition, unspecified) was added and can be used for sequela of COVID-19 as well as symptoms and conditions that follow a prior infection. This code should not be used for current infections in urgent care billing and coding.
For patients presenting without a definite diagnosis, they should be coded with the code that corresponds to each presenting problem. Here are a few examples.
- 1-R05.9 – Cough
- 02 – Shortness of breath
- 9 – Fever, unspecified
- 83 – Chills (without fever)
- 89 – Rigors
- 10 – Muscle pain
- R51 – Headache
- 9 – Sore throat
- 0 – Pain in throat
- 0 – Loss of smell
- 9 – Loss of taste
- 7 – Diarrhea
- 0 – Nausea without vomiting
- 11 – Vomiting without nausea
- 2 – Nausea and vomiting
- 9 – Chest pain (central)
- 89 – Chest pain (anterior)
- 89 – Chest Pain (non-cardiac)
- 1 – Chest pain on breathing
Asymptomatic patients on the other hand, are to be coded with Z20.822. Official guidelines state that, during the pandemic, a screening code is determined to be “generally not appropriate” since anyone could have been exposed. Even testing for preoperative situations are to be coded as exposure ICD Z20.822.
The No Surprises Act Affects Urgent Care Billing
The No Surprises Act has been a hallmark of 2022, putting in place federal protection for patients against surprise medical bills. These bills come up when consumers who have been insured receive care from out-of-network providers inadvertently. This includes doctors, hospitals, and urgent care providers that they did not choose. These bills place stress and financial burdens on patients.
The act protects consumers by requiring private health plans to take provider coverage for out-of-network claims and also apply in-network cost sharing. It also prohibits covered providers from billing patients more than the in-network cost sharing amount for these bills.
The act applies to most surprise bills, and this includes most emergency services, as well as urgent care centers licensed to provide emergency care. The No Surprises Act also covers non-emergency services that are provided by out-of-network providers in in-network hospitals and other facilities.
The COVID-19 Claims Reimbursement Program
Another highlight for urgent care billing in 2022 has been an update to claims submission. As stated by the Health Resources & Services Administration (HRSA), the program provides claims reimbursement to providers (mostly at Medicare rates), for testing individuals who are uninsured for COVID-19. It also provides reimbursement for treatment and administration of vaccines. That said, it stopped accepting claims reimbursement after March 22, 2022 for testing or treatment. For vaccine administration, claims submitted after April 5, 2022 have been denied .
Once the original $1 billion ran out from the Families First Coronavirus Response Act (FFCRA) and the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA), funding had to be allocated from elsewhere. Today, the HRSA Covid-19 Uninsured Program pulls its funding from the American Rescue Plan Act of 2021 and the legislation supporting the Provider Relief fund .
 The Journal of Urgent Care Medicine, “ICD-10 Changes for 2022,” 30 September 2021. Available: https://www.jucm.com/icd-10-changes-for-2022/.
 Centers for Disease Control and Prevention, “Social Determinants of Health: Know What Affects Health,” U.S. Department of Health & Human Services, 30 September 2021. Available: https://www.cdc.gov/socialdeterminants/index.htm.
 Health Resources & Services Administration, “COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured,” May 2022. Available: https://www.hrsa.gov/provider-relief/about/covid-uninsured-claim.
 Health Resources & Services Administration, “FAQs for COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment and Vaccine Administration,” May 2022. Available: https://www.hrsa.gov/provider-relief/about/covid-uninsured-claim/faq.