Urgent Care Center Billing Requirements
Effective Date: January 1, 2022
Purpose:
To provide guidelines for the billing and reimbursement of services rendered in Horizon contracted Urgent Care Centers.
Scope:
Products included:
- NJ FamilyCare/Medicaid
- Managed Long Term Services & Supports (MLTSS)
Definitions:
- Urgent Care: The focus of urgent care is the treatment of acute or episodic problems, and therefore, does not include coverage for routine office visits, preventative care, sports physicals, routine obstetric services, occupational medicine, physical therapy or the long-term management of chronic diseases such as cancer, diabetes, heart disease or hypertension.
Policy:
For dates of services January 1, 2022 and thereafter, services provided in Urgent Care Centers must be billed based on the level of service rendered to the member. Global services codes (HCPCS codes S9083 and S9088) will not be reimbursed. Urgent Care Centers should report the applicable evaluation and management (E&M) code in accordance with the chart below and any additional procedure codes.
Level 1 (First Aid)
| Established Patient E&M Code(s) | 99211, 99212 |
| New Patient E&M Code | 99202 |
| Criteria | Presenting problems/services that may or may not require a physician or other qualified health care professional. If the presentation requires physician level of care, it is a self-limited or minor problem requiring straightforward decision making and are minimal complex. |
| Examples | Example of services supervised by a qualified professional but performed by a non-professional supporting a level 1 include but are not limited to non-invasive specimen collection. Example of services performed supporting a level 1 service include administration of an oral pharmaceutical, a written prescription, and or non-invasive specimen collection for external laboratory processing. Note: Laboratory results must be sent to the members PCP for follow up and future treatment. |
Level 2 (Intermediate)
| Established Patient E&M Code | 99213 |
| New Patient E&M Code | 99203 |
| Criteria | Presenting problems/services that require a physician or other qualified health care professional licensure. Presenting problems are of limited complexity and require low medical decision making. |
| Examples | Example of services performed supporting a level 2 service include but are not limited to: Simple laceration repairs, simple radiological services, point of care testing which includes the collection of the specimen, venipunctures, administration of vaccines or pharmaceutical via injection, application and or provision of DME or OTC items required to support treatment, i.e., splints, slings, ace wraps, crutches. Example of conditions meeting level 2 include but are not limited to: acute intervention for a stable chronic condition, i.e., an asthmatic requiring a breathing treatment and refill of their medication, a sore throat, fever, cough, burning on urination, congestion, difficulty breathing, wheezing and superficial lacerations. |
Level 3 (Complex or Urgent)
If a member presents to an Urgent Care Center and is deferred to the emergency room, the Urgent Care Center must only bill for the services rendered and not based on the complexity of the condition.
| Established Patient E&M Code(s) | 99214, 99215 |
| New Patient E&M Code(s) | 99204, 99205 |
| Criteria | Presenting problems/services that require a physician or other qualified health care professional licensure and are of moderate or high complexity requiring moderate to high medical decision making. |
| Examples | Example of services supporting a level 2 service include but are not limited to: Casting of bones, repair of lacerations requiring sutures, removal of a foreign body, administration of IV fluids, aspirations, incision and drainages, ECG/EKG administration and vaginal specimen collection. Example of conditions meeting level 3 are those with a high risk of morbidity that pose an immediate threat to life or bodily function without treatment. For example a head injury with a brief loss of consciousness, a chronic illness with a severe exacerbation or progression that may result in hospital level of care, pulmonary embolus, MI, severe respiratory distress and or an abrupt change in neurologic status. |
A new patient evaluation and management (E&M) code should be used for members who have not received any professional services (ie, 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 CPT code(s)) from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three (3) years.
An established patient evaluation and management (E&M) code should be used for members who have not received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three (3) years.
Claims will be subject to post-service review to ensure compliance to the above. Medical records for Urgent Care services must document the time and complexity of the level of the code(s) billed.
Procedure:
Horizon NJ Health will consider for reimbursement urgent care services based on the level of procedure codes rendered.
Horizon NJ Health will not consider for reimbursement urgent care services billed with global service codes S9083 or S9088.
Horizon NJ Health will not consider for reimbursement services billed that are not supported in the medical documentation.
Resources:
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services
CMS National Correct Coding (NCCI) Initiative Edits, January 1, 2021
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.⁶
Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:
- Benefit Limitations;
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Medical necessity; and
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.