Description
This coding and billing guideline is being archived effective December 1, 2024. 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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9/24/2024
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Archiving policy as of December 1, 2024 and this policy is being combined into the NDRP-GC-034 Evaluation and Management Policy.
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