Description
To provide guidelines for the billing and reimbursement of services rendered in Urgent Care Centers, place of service (POS) 20.
Definition
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Urgent Care
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An urgent care clinic’s purpose is to treat or diagnose an acute or episodic illness or injury for an unscheduled, ambulatory patients seeking immediate medical attention. An Urgent Care Center is a distinct location from a hospital emergency room, a provider office, or a clinic.
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New Patient
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Evaluation and Management (E/M) code should be used for members who have not received any professional services (i.e., those face-to-face services) rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific procedure code(s) from the physician/qualified healthcare professional (QHP) or another physician/QHP of the exact same specialty and subspecialty who belongs to the same group practice, within the past three (3) years.
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Established Patient
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E/M code should be used for members who have received professional services from the physician/QHP or another physician/ QHP of the exact same specialty and subspecialty who belongs to the same group practice, within the past three (3) years.
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For claims processed on or after June 1, 2022, services provided in an Urgent Care Center must be billed with POS 20 and the Office Visit E/M codes based on the appropriate level of service rendered to the member. Urgent Care Centers must report the applicable (E/M) code in accordance with the American Medical Association (AMA) guidelines. Urgent Care Centers may bill for any additional services rendered during the visit that are separately identifiable from the E/M service.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
Date
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Updates
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4/8/2022
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Created Urgent Care coding and billing guidelines.
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4/3/2023
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Policy annual review completed.
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2/13/2024
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Annual review completed. Changed “Revised Date:” to “Revision Effective Date:” and added “payment integrity edits” to Limitations & Exclusions.
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