Urgent care centers occupy a vital niche in the U.S. healthcare system, offering immediate access to non-life-threatening services without the higher cost of emergency rooms. However, the hybrid nature of urgent care presents unique billing challenges. From navigating CPT and HCPCS codes to applying correct modifiers and understanding payer-specific rules, accurate billing is essential to revenue cycle health. This urgent care billing guide provides a comprehensive overview of billing principles, coding updates, and reimbursement strategies tailored specifically for urgent care providers in 2025.
CPT and HCPCS Codes in Urgent Care
Correct code selection is the foundation of compliant urgent care billing. Most urgent care services are reported using CPT codes, while certain services may also use HCPCS Level II codes:
Common CPT codes:
99202-99215 (E/M services), 36415 (venipuncture), 99051 (after-hours service), 90471 (immunizations).
Urgent care centers routinely manage lacerations, infections, fractures, and minor procedures. Examples:
- 10060: Incision and drainage of abscess.
- 12001–12007: Simple repair of superficial wounds.
- 20550: Injection of tendon sheath/ligament.
Additionally, preventive services such as flu shots (90686) and COVID-19 vaccines (91300 series) remain relevant. Review NCCI edits to avoid unbundling violations, particularly when E/M and procedures are billed together.
HCPCS ‘S’ codes:
S-codes were created for commercial insurance plans and are not part of the AMA CPT code set:
- S9083: Used by many managed care plans to represent a flat global payment for all services rendered in a visit.
- S9088: Represents an additional fee for after-hours services and is often billable with CPT E/M codes.
Notably, Medicare does not accept S-codes, requiring CPT-only reporting. As of 2025, private payers continue to vary in their acceptance of these codes. Providers must verify code coverage with individual payers to avoid denials.
CPT Disclaimer: CPT codes are copyrighted by the American Medical Association (AMA). For a full list of CPT codes and official definitions, please refer to https://www.ama-assn.org/
Key Billing Principles for Urgent Care
- Evaluation and Management (E/M) Services: Billing for E/M visits is based on either medical decision-making (MDM) or total time spent on the encounter. Level selection must match documentation and comply with 2021 E/M guidelines.
- Separately Identifiable Services: When a procedure is performed during an E/M visit, use modifier -25 to indicate the E/M is significant and separately identifiable. For example, billing 99213 with incision and drainage (10060) requires -25 on the E/M.
- Comprehensive Documentation: Documentation must support code levels, procedures performed, and medical necessity. This includes time-based billing, MDM elements, and modifier justifications.
Place of Service (POS) and Modifier Use
The designated Place of Service (POS) code for urgent care facilities is POS 20. This code indicates services provided in a freestanding facility delivering immediate, non-emergent care. POS impacts reimbursement, as it signals to payers that the visit is neither emergency room-level nor routine primary care. Incorrect POS coding can lead to claim denials or inaccurate payment rates. Additionally, some payers may interpret POS 20 differently or require additional documentation to confirm the facility meets urgent care criteria. Always verify payer-specific POS guidelines before claim submission.
Common Modifiers
Modifiers play a critical role in urgent care billing, especially when multiple services are rendered during a single visit. Common modifiers in urgent care billing are as follows:
- -25: Significant, separately identifiable E/M service.
- -59: Distinct procedural service (used to bypass NCCI edits).
- -95: Synchronous telehealth services.
- -PO: Services in a provider-based off-campus outpatient hospital department.
The use of modifiers must be justified by documentation and must be consistent with payer policies. Misapplication or omission of these modifiers often results in claim denials or downcoding. Ensuring accurate modifier use enhances reimbursement and supports payer compliance.
Medicare and Medicaid Billing for Urgent Care
Medicare
- Does not accept S-codes (e.g., S9083 or S9088).
- Uses CPT codes with POS 20 and expects accurate E/M levels.
- Documentation must meet CMS standards for medical necessity.
- Medicare Advantage plans follow CMS rules but may have additional documentation requirements.
Medicaid
- Medicaid billing varies by state.
- Some state Medicaid programs may reimburse urgent care differently or limit E/M codes.
- It is vital to review each state’s fee schedule and program manual.
Best Practices for Urgent Care Billing
- Use EHR templates that support accurate coding and modifier use.
- Conduct regular internal audits to identify undercoding or upcoding trends.
- Verify payer requirements for CPT vs. HCPCS and modifier use.
- Outsource complex billing tasks to professionals with urgent care experience.
- Stay current with updates to CPT, ICD-10, and payer policies.
Billing accuracy impacts not only compliance but also revenue cycle efficiency and claim acceptance rates.
Avoiding Claim Denials
Common claim denial reasons in urgent care billing include:
- Missing or incorrect modifiers (e.g., forgetting -25 on same-day E/M and procedure)
- Invalid use of codes like S9083 when not recognized by the payer
- Inaccurate POS or provider credentialing
Use of billing “cheat sheets” helps ensure proper CPT selection and documentation. Additionally, be cautious with incident-to billing, CMS does not allow it in urgent care settings unless all conditions are met, including direct supervision and established treatment plans. Strategies such as coding audits, payer-specific fee schedules, and modifier tracking help improve first-pass acceptance rates and overall revenue.
Conclusion
Urgent care billing is uniquely complex, blending primary care services, minor emergency procedures, and preventive care. Correct application of CPT and HCPCS codes, modifiers, and place of service designations is essential for timely and accurate reimbursement. Medicare, Medicaid, and private payer policies each have their own billing guidelines that require specialized knowledge. By following industry best practices and keeping up with evolving guidelines, urgent care providers can ensure clean claims and maximize revenue.
Outsourcing Urgent Care Billing: Is It Worth It?
Outsourcing urgent care billing can lead to faster payments, fewer denials, and increased focus on patient care. Many urgent care centers choose third-party billing partners to navigate complex CPT rules, evolving payer policies, and documentation standards.
Billing experts familiar with urgent care-specific codes, modifiers, and payer nuances can optimize revenue cycle performance. Additionally, outsourced teams handle payer follow-ups, appeals, and reporting, all of which are crucial in urgent care’s high-volume environment.
Need help navigating urgent care billing complexities? Medisys provides full-service urgent care billing with proven expertise, helping providers minimize claim errors and maximize collections without disrupting clinical workflows. Contact us today to schedule a consultation.
