Urgent care coding and billing updates: What changed for 2025?

Urgent care coding and billing updates

 Commonly Billable Procedures in Urgent Care

Procedures on the same date (modifier 25)

  • It is appropriate to bill -25 for an E/M when work goes beyond the procedure itself – for example, a laceration repair plus an unrelated evaluation.
  • Be sure to include HPI, exam, and MDM for the distinct problem, as well as a separate assessment and plan to justify the E/M level in your note. You should always follow the guidelines of NCCI.

Place of Service (POS)

  • POS 20 = Urgent Care Facility. Use for true UC centers per contracts.
  • POS 11 = Office (don’t use if you’re contracted/broadcasting as urgent care).
  • Telehealth: POS 10 = patient home; POS 02 = telehealth other site. Pair with modifier 95 when the payer requires it. Always check payer rules.

Telehealth (what’s still allowed now)

  • Telehealth through Sept 30, 2025: Medicare allows patients to be at home and permits audio-only visits for certain non-behavioral services. Always check CMS’s current telehealth code list before billing. Private insurers often follow similar rules but may vary.
  • “Incident-to” billing: Rarely applies in urgent care. Medicare requires an established plan of care and direct supervision in the office. New patients or new problems do not Most urgent care visits should be billed under the rendering clinician’s own NPI.

Documentation pointers that protect payment

  • Medical necessity first. Note why the patient chose urgent care (onset, severity, risk if untreated).
  • Tie tests to diagnoses. Each ordered test should have a clinical reason/working dx.
  • If using modifier 25: create a clearly separated E/M section for the distinct problem; avoid copy/paste.
  • Procedures: include consent (if applicable), site, anesthesia, technique, closure materials/length, complications, and aftercare.
  • Telehealth: document patient location, provider location, modality (audio-video vs. audio-only), and consent.
  • ICD-10 FY2025: confirm your diagnosis choices exist in FY25 (some codes changed Oct 1, 2024).

Billing checklist

  1. Pick POS: 20 for on-site UC; 10/02 for telehealth (payer rules).
  2. Level E/M via MDM or time (no double-counting procedure work).
  3. Add procedures (lac repair, I&D, fracture care, splinting, injections, X-ray, EKG, POC labs).
  4. Apply modifiers:
    • -25 with E/M when distinct and significant.
    • -59/X{EPSU} for unbundling when appropriate (follow NCCI).
    • -95 for synchronous telehealth if payer requires.
  5. Vaccines: product + correct admin code(s).
  6. Diagnosis codes: use FY2025 ICD-10-CM.
  7. Payer-specific rules: check MA plans/Medicaid/MCOs for their own POS, telehealth, and modifier edits.
  8. Fees: load the 2025 fee schedules; be aware of the PFS reduction when planning rates.

Notes on denials we’re seeing (and how to prevent them)

  • Overuse of G2211: Denied when encounter is clearly episodic. Train staff: “Urgent care = no G2211” unless you truly manage ongoing care.
  • Modifier 25 down codes/denials: Lacks clear documentation of a separate E/M. Separate the work with problem-oriented headings.
  • Missing POS/95 information: Make sure that the POS/95 matches the patient’s location and the mode of communication (audio or video) is specified within the allotted time frame.
  • Outdated ICDs: Favourites list still on old codes—refresh to FY2025 set.
  • G2211 “visit complexity” add-on:
    • Still for longitudinal/ongoing relationships, not one-off/episodic visits—so most urgent care encounters won’t
    • New for 2025: CMS will pay G2211 even when modifier 25 is on the base E/M—but only in allowed scenarios (e.g., certain Part B preventive services). This doesn’t override the “longitudinal” rule above.
  • Telehealth flexibilities (Medicare): Patient can be at any location, including home, through Sept 30, 2025. After that, restrictions will tighten unless they are extended again. Use POS 10 (home) or POS 02 (other), and modifier 95 when required by the payer.
  • ICD-10-CM FY2025: Code set in effect Oct 1, 2024–Sept 30, 2025 (252 new, 36 deleted, 13 revised). Ensure that your problem-list maps and favourites accurately reflect the FY25 changes.
  • Modifier 25 scrutiny remains high: Use it only when a significant, separately identifiable E/M is performed in addition to a procedure the same day; align with 2025 NCCI policy language and payer policies.

 Payer & contract checks (musts)

  • Always review each payer’s contract: some payers require urgent care to bill as POS 11 (office) for payment parity, others accept POS 20. Contract language overrides general CMS POS guidance. Check MA plans and Medicaid separately — state rules differ.

 Quick institutional (UB-04) checklist for urgent care claims

  1. Provider NPI and facility NPI placed correctly.
  2. Correct Type of Bill and Revenue Codes for each service (e.g., 0456 for urgent care department if used by contractor).
  3. CPT/HCPCS codes in Box 44 match revenue code descriptions.
  4. Diagnosis codes (ICD-10) valid for DOS (FY2025 set if after Oct 1, 2024).
  5. Modifiers (TC/26, 59/X, 25, QW, 95) used appropriately and documented.
  6. Itemized charges for supplies/drugs with HCPCS J/A codes if billable.
  7. Attach clinical documentation on appeal if denied for medical necessity.

 Where to check authoritative updates (use these regularly)

  • CMS Place of Service code table (POS list).
  • CMS OPPS / APC final rule and CR updates (for hospital-owned urgent care / facility payment changes).
  • Local Medicare contractor guidance for revenue codes and UB-04 completion (e.g., Noridian).
  • Medicare Claims Processing Manual Chapter 25 — UB-04 instructions.

MEDICARE PFS

  • Medicare conversion factor cut: Overall PFS payments dropped ~2.9% for 2025. Expect payer updates and fee schedule refreshes
  • Facility fee denied for freestanding centers: check if the payer considers the site facility-eligible or if contract denies facility fees for freestanding urgent care — many commercial contracts exclude facility fees for freestanding urgent care. Fix: confirm contract language and resubmit as professional only if required.
  • Split billing errors (TC/26) / missing revenue codes: when radiology billed in wrong component, denials occur. Fix: split charges correctly and include documentation for interpretation.
  • Lab/POC coding (QW) incorrect or missing — verification of CLIA status and correct modifier reduces denials.
  • Incorrect POS — POS 11 vs 20 mismatches cause payment issues. Fix: align POS with patient location and payer contract.
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