Journal of Urgent Care Medicine

A Basic Guide to Coding Denials and Diagnosis Compliance

Samantha Etter, CPC; Reanna Nelson, CPC Healthcare reimbursement processes continue to evolve. In 2026, diagnosis-based denials have increased significantly across multiple payer types. Unlike procedural denials, diagnosis denials often stem from policy interpretation rather than incorrect coding. For urgent care, each denial impacts revenue cycle performance, increases administrative burden, delays reimbursement, and raises compliance concerns. Understanding the root causes behind diagnosis denials is essential for proactive prevention and long-term revenue integrity. Historically, diagnosis denials were …

New ‘Visual Combo’ Code Brings Reimbursement Risks

Effective January 1, 2026, the Centers For Medicare and Medicaid Services mandated a critical coding change for urgent care: Visually read COVID-19/flu combination tests must now be billed under the single code CPT 87812. This replaces the previous standard of unbundling the tests into 2 separate codes (CPT 87811 and CPT 87804) and was intended to be revenue-neutral. However, a national analysis of January 2026 data by Urgent Care Consultants exclusively for JUCM reveals a …

Mitigating Coding Compliance Risks of AI Documentation Tools

Three types of artificial intelligence (AI) technologies are quickly moving to the urgent care exam room: real-time transcription; real-time coding; and clinical decision support systems.[1] They promise to reduce clinician burden per visit, improve documentation in the medical record, reduce cost per episode of care, and improve reimbursement. They may create challenges related to clinical ownership, medical decision making, and compliance, however.[2] Notes and code suggestions generated by AI for urgent care patients are likely …

Billing Integrity in Urgent Care: How to Manage Risk

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC, is Revenue Integrity Manager at Experity. The financial and reputational health of an urgent care practice depends on one simple principle: Bill accurately and compliantly. Yet as reimbursement rules evolve and staffing models shift toward greater reliance on non-physician practitioners (NPPs), many centers find themselves at risk for costly missteps. From billing under the wrong provider to out-of-network (OON) complications and False Claims Act (FCA) violations, administrators are …

Mastering Revenue Cycle Management

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC Revenue cycle management (RCM) may not be the most glamorous part of urgent care, but it is one of the most critical. A clinic can provide excellent patient care, yet still struggle to keep its doors open if its billing processes falter. Too often, urgent care leaders rely on assumptions, outdated practices, or incomplete data that lead to financial surprises and lost revenue. Running an effective Revenue Cycle …

ICD-10 Changes Impacting Urgent Care in 2025

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, …

Navigating Payer Reviews and Medical Decision-Making: A Critical Guide for Urgent Care

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 …

Debate Continues On Acuity and Coding Trends in Urgent Care

A new study suggests there has been a rise in higher acuity coding across certain outpatient services. Among urgent care centers, the proportion of visits coded at higher complexity levels (CPT 99204 and 99205) increased overall from 34.0% in 2018 to 40.6% in 2023, while visits coded at level 1 (CPT 99202) declined from 9.5% to 2.9% over the same period. The most significant increases in high-intensity coding were observed in cases involving “blood and …

What’s New in Telemedicine for 2025?

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC The American Medical Association (AMA) added a Telemedicine Services category to the Evaluation and Management (E/M) section of the Current Procedural Terminology (CPT) code set. Codes are divided up by the technology used and the patient type (ie, new vs. established). These codes are for synchronous, real-time interactive encounters between the provider and the patient. Codes are leveled by medical decision making (MDM) or time, which is similar …

ICD-10-CM: What’s New for 2025

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC We are heading into fall, and fall starts with updates to the ICD-10-CM codes. The most recent changes went into effect on October 1, 2024. There is no grace period. Because ICD-10-CM codes are date-specific, claims prior to date of service October 1, 2024, need to use the codes for that time period, switching over to the update on the exact day. While ICD-10-CM codes are updated semi-annually, …

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