The healthcare industry is adapting quickly, and urgent care centres are the major reason for providing efficient and timely healthcare services to millions of patients globally. According to the stats, urgent care clinics managed around 89 million patient visits in 2024, which represents 29% of primary care and 15% of outpatient visits in the US. With such rising demand for urgent care services, healthcare professionals and organizations need to stay updated with urgent care CPT codes to use reasonably for medical billing and reimbursement. Don’t worry!
What are Urgent Care CPT Codes?
Urgent Care CPT Codes are special five-digit codes that healthcare professionals and urgent care centers use to describe the medical service they provide to patients. It may include Evaluations and check-ups (E/M visits), Minor surgeries, Diagnostic tests (like X-rays or lab work), and Treatments or therapies. When the urgent care clinic uses these urgent care CPT codes, then it helps the insurance companies identify which medical service is used, and they get paid correctly for the service. These codes are very essential for clinics to get fair reimbursements for their medical services, and that’s why choosing the correct CPT code is also necessary.
Why CPT Codes Matter in Urgent Care Billing?
Urgent Care CPT Codes are essential for clinics to ensure smooth medical billing services. These codes identify how minor or significant treatment is provided to patients, and they help ensure fair reimbursement. There are so many Urgent CPT codes available for different medical services, and using the correct code is essential to avoid claim denial or rejection. That’s why every healthcare professional or urgent care clinic needs to stay updated with urgent CPT codes and use them correctly for fair reimbursement.
Challenges of Urgent Care Coding and Billing
Here are some common challenges that urgent care centers face while medical billing and coding:
1. Lack of Time
Urgent care centers are known for their urgent care, and patients are treated quickly without checking whether their insurance will cover the visit. This can lead to errors when submitting bills to insurance companies.
2. Varying Insurance Rules
Every insurance company has its own set of rules for accepting claims. If one code is accepted by one insurer, it may be rejected by another, causing delays and making the billing process complex.
3. Confusing Guidelines
Urgent care CPT codes have confusing guidelines, making it hard to pick the right one for medical services during billing. Clinics must know each urgent care CPT code and follow the unique requirements of each insurance provider.
4. Medicare Payments
Medicare pays only 80% of the cost of urgent care services, which is less than what private insurance companies usually cover. This means clinics often don’t need to get the total amount they owe.
Common Modifiers Used in Urgent Care Billing
Urgent care centers use modifiers to explain the details of the medical services provided to the patient during a visit through a telehealth app. It is mainly used when multiple medical services are provided. Here are some common modifiers used in urgent care billing:
Modifier 25: Separate E/M Service on the Same Day
This modifier is used when a doctor does an evaluation or check-up (E/M service) on the same day as another procedure, but both procedures are different and unrelated. By using this modifier, the doctor tells the insurance company that both services are needed and not part of the same treatment. For Example, if a patient comes in for a wound treatment but also needs a check-up for a cough, then the doctor uses this modifier to show both services.
Modifier 59: Different Procedure Done
This modifier is used when two procedures are performed during the same visit and don’t usually belong together. It shows the insurance company that the procedures are separate and should be paid separately. For Example, if a patient gets a wound stitched up and also gets an X-ray at the same time, then this modifier shows two different procedures.
Modifier 24: Unrelated Service After Surgery
This modifier is used when a patient comes back to an urgent care clinic for a service unrelated to a previous surgery. It shows that the follow-up surgery is not related to the surgery. For Example, if a patient who had surgery for a fracture comes back to treat a cough, then this modifier is used to show that both services are different.
Modifier 76: Repeat Procedure by Same Doctor
This modifier is used when the same doctor performs the same procedure again on the same day. It shows that the repeat procedures were necessary. For Example, if a patient needs the same X-rays done twice during the same visit because of a changing condition, then this modifier is used to showcase the need to the insurance company.
Modifier 51: Multiple Procedures
This modifier is used when more than one procedure is performed during the same visit. It shows the insurance company that multiple procedures are essential. For Example, if a patient gets a fracture treated and also has a foreign object removed from a wound, this modifier is used to show the importance.
Modifier 52: Reduced Service
This modifier is used when a planning procedure is started but needs to be completed or if only part of the procedure is done. For Example, if a surgery is planned but stopped halfway for any reason, then this modifier shows that the service was reduced.
Modifier 57: Decision for Surgery
This modifier is used when a doctor decides that surgery is needed. It tells the insurance company that the decision to perform surgery was made after the patient evaluation. For Example, if a doctor evaluates a patient and decides that surgery is needed, then this modifier is used to show the decision.
Changes to Urgent Care CPT Codes in 2025
Every year, there are new updates under the American Medical Association (AMA) in CPT codes, and this 2025 brings new changes every urgent care center needs to know:
Remote Monitoring Updates: All the CPT Codes for remote therapeutic monitoring (RTM) now include digital therapies and the supplies needed for devices to send or access data.
New AI Codes: Seven new CPT codes (0877T-0880 T) were added for using AI in medical services, such as analyzing ECGs and chest images.
Surgery Code Updates: New CPTs have been added for advanced techniques in tumor removal from the abdomen (49186-49190) and improved procedures for skin grafts (15011-15018).
These are some recent changes in the CPT codes that every healthcare professional and urgent care center needs to be updated.
Compliance and Regulatory Considerations
In the fast-changing world of healthcare, urgent care centers need to stay updated with the changes and follow the guidelines and regulations carefully. Some of the standard regulatory compliance is HIPAA, which protects patients’ information and ensures each patient’s privacy is secured. Organizations like the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) set these rules that every urgent care center needs to follow to avoid penalties or legal issues. It requires staying updated with changes in codes like CPT code 99213.
Best Practices for Using Urgent Care CPT Codes
Here are some best practices that every urgent care center needs to follow while using Emergency CPT codes:
1. Keep Detailed Records
Whenever a patient visits, always write down everything about the patient visit, including health history, tests, treatments, and how the patient responded. Having all these details helps healthcare professionals find the correct CPT code.
2. Do Regular Audits
Regular audits and billings are essential to ensure everything is correct. They also help catch mistakes early before they cause problems like payment delays or rejections.
3. Stay Updated on Code Changes
Every year, CPT codes undergo new changes, and it’s essential to stay updated with them. This ensures that you’re using the most accurate codes and avoids mistakes that lead to claim denials.
4. use the Right Modifiers
Modifiers provide additional details about the services provided by the centers. The right modifier can explain the care given and ensure proper claims.
5. Train Your Team
Every healthcare organization should train its staff to understand the latest coding rules and changes. Regular training helps them handle tricky cases and use the correct CPT codes for accurate billing.
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