Commonly Billable Procedures In Urgent Care: A 2025 Medical Coding Guide

By Author: Albert
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Accurate billing and coding in urgent care settings are critical for compliance, timely reimbursement, and minimizing denials. As payer rules evolve, urgent care providers must ensure correct use of medical coding services and stay aligned with CMS and private payer requirements. Partnering with expert medical coding companies or leveraging medical coding outsourcing solutions can help practices avoid costly errors, streamline workflows, and improve revenue integrity.
Procedures on the Same Date (Modifier 25)
Modifier 25 applies when an E/M service goes beyond the procedure itself—for example, performing a laceration repair plus an unrelated evaluation. Always include HPI, exam, and MDM for the distinct problem, along with a separate assessment and plan to justify the E/M level. Documentation must follow NCCI guidelines.
Place of Service (POS)
POS 20: Urgent Care Facility (use for true UC centers as per contracts).

POS 11: Office (avoid if contracted as urgent care).

Telehealth POS: 10 (patient home), 02 (telehealth other site). Pair with modifier 95 when payers require it. ...
... Always verify payer-specific rules.

Telehealth Services (Valid 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. Commercial insurers often follow similar guidelines but may vary.
“Incident-to” Billing
Rarely applies in urgent care. Medicare requires a plan of care and direct supervision. New patients or new problems do not qualify. Most visits should be billed under the rendering clinician’s NPI.
Documentation Pointers That Protect Payment
Medical necessity: Document why urgent care was chosen (severity, risk, onset).

Tests: Tie each test to a diagnosis.

Modifier 25: Clearly separate the E/M section for distinct problems.

Procedures: Include consent, site, anesthesia, closure details, complications, and aftercare.

Telehealth: Document patient/provider location, modality, and consent.

ICD-10 FY2025: Confirm diagnoses exist in the updated set.

Billing Checklist
Select correct POS (20 onsite, 10/02 telehealth).

Level E/M via MDM or time (don’t double-count procedure work).

Add procedures like fracture care, I&D, injections, X-ray, EKG, and POC labs.

Apply modifiers (-25, -59/X{EPSU}, -95 as required).

Use correct ICD-10-CM FY2025 diagnosis codes.

Review payer-specific rules for telehealth, modifiers, and urgent care POS.

Notes on Denials (and Prevention)
Overuse of G2211: Denied if encounter is episodic. Train staff: urgent care ≠ G2211.

Modifier 25 denials: Avoid without clear documentation of a distinct E/M.

Missing POS/95: Ensure documentation matches patient location and modality.

Outdated ICDs: Update favorites and problem-lists with FY2025 codes.

G2211 Add-On Code (2025 Update)
CMS will pay G2211 even with modifier 25 on the base E/M but only for allowed scenarios (certain Part B preventive services). This doesn’t override the rule that G2211 applies mainly to longitudinal relationships.
Payer & Contract Checks
Always verify payer contracts. Some require POS 11 for payment parity, while others accept POS 20. Medicaid and MA plans may have unique state-specific requirements.
UB-04 Checklist for Urgent Care Claims
Correct provider and facility NPIs.

Appropriate Type of Bill and Revenue Codes (e.g., 0456).

CPT/HCPCS codes aligned with revenue descriptions.

Valid ICD-10-CM FY2025 codes.

Correct modifiers (TC/26, 59, 25, 95, QW).

Itemized charges for drugs/supplies with HCPCS J/A codes.

Attach documentation if denied for medical necessity.

Key Updates and References
Medicare PFS 2025: Conversion factor cut by ~2.9%.

Facility fees: Often denied for freestanding centers—confirm contracts.

Split billing errors: Ensure correct TC/26 use.

Lab/POC coding: Verify CLIA status and QW modifier.

Incorrect POS: Common cause of denials—align with payer contract.

Why Outsourcing Medical Coding for Urgent Care Matters
Given the complexity of urgent care billing, many practices partner with specialized medical coding companies or choose medical coding outsourcing for accurate coding, compliance, and denial prevention. By leveraging professional medical coding services, urgent care providers can:
Ensure accurate POS, modifiers, and ICD-10-CM coding.

Stay current with payer-specific updates and CMS regulations.

Reduce claim denials and accelerate reimbursement cycles.

Free up staff time to focus on patient care rather than administrative tasks.

Read more: https://www.allzonems.com/urgent-care-billing-coding-guide-updates/