Revenue Cycle Management

Tricia Krueger, CPC, is RCM Coding Supervisor for Experity. ICD-10 has been ever changing since it was first adopted 10 years ago. Each year, the Centers for Medicare & Medicaid Services (CMS) revise, add, and delete diagnoses to better suit the conditions, including the conditions that present in urgent care centers. These changes reflect advances in clinical understanding and the need for more precise documentation in fast-paced care settings. While ICD-10 changes can happen semi-annually, most changes happen in October. For the upcoming 2025-2026 update, there are 487 new codes, …
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Nikki Benedict Timely filing is a critical concept in medical billing that directly impacts claim reimbursement. Despite its importance, the specific requirements and terminology can vary across payer contracts, making it essential for billing teams to understand both the general rules and the payer-specific nuances. When reviewing a payer contract, timely filing requirements may be outlined under the following sections: Submission/Adjudication of Claims Payment Time to File Claims Providers can find Medicare and Medicaid timely filing requirements by consulting Centers for Medicare & Medicaid Services (CMS) and relevant state Medicaid …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC In the healthcare ecosystem, credentialing is more than a bureaucratic hurdle—it’s the linchpin of successful revenue cycle management. For urgent care centers, credentialing determines whether providers can be reimbursed for the care they deliver to insured patients and whether they can participate in insurer networks. Credentialing is the formal process by which payers—commercial insurance companies, Medicare, and Medicaid—verify the qualifications, training, licensure, and work history of care providers. It is a prerequisite for reimbursement, as only credentialed providers can bill for services rendered …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC Urgent care operators face increasing challenges from payer reviews—a situation exacerbated by ongoing confusion around coding guidelines and proper documentation of medical decision-making (MDM). As more urgent care providers grapple with administrative burdens and financial pressures, understanding how to document and code accurately has never been more important. The Rise of Payer Reviews Pre-payment reviews have become commonplace, initiated when a provider’s billing patterns—such as a higher frequency of level 4 visits compared to peers—trigger payer scrutiny. Practices might receive notification letters identifying …
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Urgent care centers serve a crucial function in providing prompt and accessible healthcare, but they encounter unique challenges in managing their revenue cycle, particularly in reducing claim denials. Unlike primary care or specialized medical practices, urgent care clinics often treat patients on a one-time basis, making both patient intake and billing more complex. Additionally, frequent turnover among front desk staff contributes to recurring errors in patient registration, insurance verification, and claims processing, all of which raise the likelihood of denials. Denied claims can delay reimbursements, increase administrative burdens, and negatively …
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