In the fast-paced world of urgent care, where patients walk in without appointments and expect swift solutions, billing departments are just as fast-moving, but with a twist of complexity. If you’ve ever worked behind the scenes in urgent care billing, you know it’s more than just punching in a few codes. It’s a calculated dance between CPT codes, ICD-10 specifics, payer policies, and ever-shifting reimbursement structures. In 2025, this dance has some new steps—and if you want to get paid correctly and on time, you’d better learn them.
Whether you’re a clinic administrator, coder, or provider trying to make sense of those EOBs, this blog will decode the chaos with clarity. We’ll focus solely on the billing and coding intricacies, guiding you through the CPT codes, ICD-10 rules, reimbursement rates, and what’s new in 2025 for urgent care billing.
1. The Billing Framework: Why Urgent Care Is Unique
Unlike primary care or emergency departments, urgent care straddles a middle ground. It deals with episodic care but often requires the use of evaluation and management (E/M) services, point-of-care testing, minor procedures, and rapid documentation—all within the same visit. This complexity impacts how services are billed and what payers expect.
Key Characteristics in Billing:
| Element | Description |
| Volume-based | High patient turnover means high coding accuracy is needed. |
| Walk-in nature | Pre-authorization rarely applies |
| Hybrid care models | Can include both office visit (99202-99215) and ED-style codes |
| Facility vs Non-facility | Payment rates differ based on ownership (physician-owned vs hospital) |
2. Most Common CPT Codes in Urgent Care
In 2025, urgent care clinics still rely heavily on Evaluation & Management (E/M) codes. However, nuances in documentation and visit complexity have made code selection more critical than ever.
Common E/M Codes:
| CPT Code | Description | 2025 Reimbursement (Avg, Non-facility) |
| 99202 | New patient, straightforward, 15-29 min | $70-$85 |
| 99203 | New patient, low complexity, 30-44 min | $110-$125 |
| 99204 | New patient, moderate complexity, 45-59 min | $165-$180 |
| 99212 | Established patient, straightforward, 10-19 min | $55-$65 |
| 99213 | Established patient, low complexity, 20-29 min | $90-$105 |
These values are CMS averages and may vary by region and payer contract.
3. Common ICD-10 Codes Seen in Urgent Care
Urgent care centers see everything from strep throat to minor burns to UTI to sprains. ICD-10 coding must be precise to support medical necessity and ensure correct reimbursement.
Top ICD-10 Codes in Urgent Care (2025):
| ICD-10 Code | Condition | Notes |
| J06.9 | Upper respiratory infection | Very common, requires a clear HPI |
| N39.0 | Urinary tract infection | Lab results are needed in some cases |
| S93.401A | Ankle sprain (unspecified, init) | Use “A” for initial encounter |
| L03.115 | Cellulitis of the lower limb | Linked with antibiotic treatment |
| R50.9 | Fever, unspecified | Avoid using alone without detail |
2025 Coding Tip: Many payers are tightening scrutiny on “vague” diagnoses like R10.9 (unspecified abdominal pain). Use more specific sub-codes where possible to avoid denials.
4. Billing Tips for Clean Claims
Even seasoned coders can trip up on common billing pitfalls. Here are fresh tips for urgent care billing in 2025:
Tips for Maximum Reimbursement:
- Time-based documentation: Since 2021, E/M services can be time-based, especially helpful in urgent care.
- Use Modifier 25 when a procedure (like an injection or x-ray) is performed during the same E/M visit.
- Always check payer policies on urgent care designation—some require place-of-service (POS) 20 to trigger proper reimbursement.
- Charge for supplies using HCPCS codes (like A4550 for surgical trays), especially for procedures.
5. What’s New in 2025?
The Centers for Medicare & Medicaid Services (CMS) has introduced a few updates for urgent care coding and billing:
- Revised RVUs (Relative Value Units): E/M codes now have slightly higher RVUs across levels 99203–99213.
- Tele-urgent care integration: CMS has added reimbursement codes for tele-urgent care under certain POS and modifier structures.
- Increased auditing for 99214/99204: If you’re frequently using high-complexity codes, expect audits unless documentation supports it.
FAQ Corner: Real Questions from Real Clinics
Q: Can we bill for both E/M and a procedure in the same visit?
A: Yes, but append Modifier 25 to the E/M code. Make sure your documentation supports a separately identifiable service.
Q: Is POS 20 mandatory for urgent care billing?
A: Not for all payers, but many commercial plans and Medicaid MCOs require POS 20 to reimburse at urgent care rates.
Q: Are telehealth visits billable for urgent care in 2025?
A: Yes—especially when using codes like 99441–99443 or G2025 with place-of-service 02 or 10. Always check payer guidelines.
Urgent Care Billing in 2025: Mastering the Code Game
If urgent care billing were a video game, modifiers would be your cheat codes. They help you unlock extra reimbursement, explain special situations, and prevent unnecessary denials. But use the wrong one—or forget it entirely—and your claim might just disappear into the insurance void.
1. Modifier Mastery: The Small Symbols That Change Everything
Modifiers are two-digit codes added to CPTs to indicate a service or procedure has been altered without changing the core definition.
Most Common Modifiers in Urgent Care:
| Modifier | Meaning | When to Use |
| 25 | Significant, separately identifiable E/M | Use when a procedure is done during the same visit. |
| 59 | Distinct procedural service | Use for bundled procedures that were done separately. |
| 91 | Repeat the clinical diagnostic lab test | For repeat tests on the same day. |
| 95 | Synchronous telemedicine service | For real-time audio/video urgent care visits. |
| TC/26 | Technical/component split | For diagnostic services where billing is split, e.g., x-ray. |
2025 Tip: Overuse of Modifier 25 is triggering payer audits. Be sure to clearly separate documentation for the E/M and procedure.
2. Procedures in Urgent Care: The Most Billable Moments
Urgent care is more than coughs and colds. Clinics frequently perform minor procedures that, if billed correctly, add substantial revenue. Here’s what to watch for in 2025.
Common Procedure CPT Codes in Urgent Care:
| CPT Code | Procedure | 2025 Avg Reimbursement (Non-facility |
| 96372 | Therapeutic injection, e.g., Toradol | $20-$35 |
| 12001 | Simple laceration repair, like 2.5cm or less | $120-$135 |
| 20610 | Large joint injection, e.g., knee | $125-$145 |
| 82962 | Glucose fingerstick | $8-$10 |
| 93000 | Electrocardiogram with interpretation | $20-$25 |
Coding Pearl: If you bill an E/M visit and perform a joint injection (20610), you must append Modifier 25 to the E/M to justify both services.
3. Lab Billing in Urgent Care: Quick Tests, Big Revenue
Labs are the heart of urgent care. From strep tests to urinalysis, these quick tests are vital for clinical decisions—and highly billable.
Most Common Lab Codes and Their 2025 Rates:
| CPT Code | Test Name | 2025 Reimbursement Non-facility |
| 87880 | Rapid strep test | $15-$20 |
| 81002 | Urinalysis, dip stick only, non-automated | $5-$7 |
| 36415 | Routine venipuncture | $3-$5 |
| 87635 | COVID-19 PCR | $45-$55 |
| 87426 | SARS-CoV-2 antigen | $30-$35 |
Pro Tip: Always ensure CLIA certification is active and on file with payers to avoid lab denials. Include it in your claims if required.
4. Real-World Billing Scenario: Doing It Right
Scenario:
A patient walks into urgent care complaining of a sore throat and fever. The provider performs an E/M, a rapid strep test, and gives a Toradol injection.
Correct Billing Setup:
| Service | CPT Code | Modifiers | ICD-10 |
| New patient E/M | 99203 | 25 | J02.9 Pharyngitis |
| Rapid strep test | 87880 | — | Same |
| Therapeutic injection of Toradol | 96372 | — | R50.9 Fever |
Payer Notes:
- Modifier 25 must be applied to the E/M code.
- Use the correct ICD code to support each procedure.
- If documentation lacks clarity, you risk bundling denials.
Total Estimated Reimbursement (2025):
$125 (E/M) + $18 (Strep) + $30 (Injection) = $173
5. Watch for These Billing Pitfalls
Even in 2025, some mistakes still happen too often. Avoid these common billing errors:
- Using bundled codes (like billing 36415 separately during a bundled service).
- Failing to append Modifiers, especially 25, when services are truly distinct.
- Neglecting time documentation for time-based E/M selection.
- Upcoding E/Ms without proper documentation—expect audits!
Urgent Care Billing in 2025: The Payer Puzzle and Telehealth Twist
Billing in urgent care isn’t just about choosing the right codes—it’s about understanding who you’re billing and how they want things done. Medicare, Medicaid, commercial payers—they all speak slightly different billing languages. And with 2025 bringing in new policies, modifiers, and telehealth expansions, urgent care billing teams need to keep their coding game sharp.
Let’s explore the payer-specific nuances, 2025 reimbursement trends, and how to get paid faster while reducing denials.
1. Reimbursement Updates for Urgent Care in 2025
This year, CMS and many commercial payers have adjusted the RVUs (Relative Value Units) and payment rates for common services in urgent care. Some services are seeing modest increases, especially E/M visits and telehealth codes, while others—like bundled labs—are seeing reduced payments.
What’s New in 2025:
| Area | Change |
| E/M RVUs | Increased by 2-3% for levels 99203-99213 |
| Telehealth visits | Expanded coverage for urgent care with higher pay parity |
| Bundled services scrutiny | More bundling; fewer “a la carte” reimbursements |
| Modifier 25 audits | Stronger enforcement and documentation requirements |
| CMS split/shared billing | Now allowed in more urgent care settings with NPPs |
Reimbursement Insight: A Level 3 new patient visit (99203) now reimburses approx. $110–$125 (non-facility), up from ~$105 in 2024. Not massive, but meaningful in high-volume settings.
2. Payer-Specific Billing Nuances
Each payer treats urgent care a little differently. Let’s break down how to approach the big ones.
Medicare:
- Still uses POS 20 for urgent care centers.
- Telehealth for urgent care is reimbursed using G2025, 99441–99443, or E/M with Modifier 95, depending on encounter type.
- CLIA certificates must be linked for labs.
- Enforcing MIPS documentation requirements for providers.
Medicaid:
- Varies significantly by state (e.g., PA Medicaid requires separate authorization for certain in-office procedures).
- Bundled payments are more common.
- Often requires T-codes or S-codes for specific services.
Commercial Payers (e.g., Aetna, BCBS, UHC):
- Tend to require Modifier 25 and POS 20 for E/M + procedure combo payments.
- Deny vague ICD-10 codes more aggressively (e.g., R10.9 – unspecified abdominal pain).
- Increasing use of prepayment reviews—claims flagged before being paid.
3. Tele-Urgent Care Billing: Virtual, Real Profits
COVID-19 changed the rules of engagement, and telehealth is now firmly part of the urgent care model. In 2025, billing for tele-urgent care has matured, but nuances remain.
CPT Codes for Telehealth in Urgent Care:
| CPT Code | Description | POS | Modifier |
| 99441 | Telephonic E/M, 5-10 minutes | 02 or 10 | 95 |
| 99442 | Telephonic E/M, 11-20 minutes | 02 or 10 | 95 |
| 99212-99214 | Standard E/M via telehealth | 02 or 10 | 95 |
| G2025 | CMS-specific code for rural health telehealth | 02 | — |
Tip: Use POS 10 (patient’s home) instead of POS 02 when the visit is truly remote—many payers now reimburse at parity with in-person visits if billed this way.
4. Top Denials in Urgent Care Billing—and How to Beat Them
Denials in urgent care billing are more than frustrating—they’re expensive. Here are the most common culprits in 2025 and ways to stop them at the source.
Common Denials & Fixes:
| Denial Reason | Prevention Strategy |
| E/M denied due to missing Modifier 25 | Always use Modifier 25 if a procedure is performed |
| Procedure denied as “not medically necessary.” | Link to a specific ICD-10 code showing necessity |
| Lab denied due to missing CLIA | Include the CLIA number in the billing profile/claim |
| Duplicate claim submission | Use appropriate modifiers (e.g., 91 for repeat labs) |
| POS not matching service type | Double-check check payer’s POS requirement (e.g., POS 20) |
Pro Tip: If you’re using software with automated coding features, ensure it includes logic for Modifier 25 and lab bundling rules—or you’ll face high rejection rates.
5. 2025 Tips for Smoother Reimbursement
Update payer contracts: Make sure your contracts reflect updated 2025 RVUs and telehealth parity terms.
Audit E/M documentation monthly: Especially if your providers are using 99204/99214 often—CMS has targeted these codes for overuse reviews.
Train providers on time-based coding: This allows for better E/M levels with proper documentation and avoids unnecessary denials.
Invest in denial tracking tools: Don’t just resubmit—fix root causes to prevent repeat issues.
Urgent Care Billing in 2025: CPT + ICD-10 Cheat Sheets & Revenue Power Moves
If billing were a race, speed alone wouldn’t win—you’d need precision, documentation, and a deep knowledge of what codes go with what diagnosis. That’s why urgent care coders and billers need something more practical than just guidelines—they need cheat sheets, smart workflows, and a revenue mindset.
1. CPT Code Cheat Sheet for Urgent Care in 2025
These are your high-frequency, high-yield CPT codes. Post them in every billing workstation or embed them into your EHR templates to cut coding time.
Evaluation & Management:
| CPT Code | Description | 2025 Avg Pay |
| 99202 | New pt, straightforward, 15-29 mins | $75-$90 |
| 99203 | New pt, low complexity, 30-44 mins | $110-$125 |
| 99213 | Est. pt, low complexity, 20-29 mins | $90-$105 |
| 99214 | Est.pt, moderate, 30-39 mins | $120-$135 |
Procedures & Injections:
| CPT Code | Description | 2025 Avg Pay |
| 96372 | Therapeutic injection | $25-$35 |
| 12001 | Simple wound repair <2.5cm | $120-$135 |
| 20610 | Large joint injection | $125-$145 |
Labs & Diagnostics:
| CPT Code | Description | 2025 Avg Pay |
| 87880 | Rapid strep | $18-$22 |
| 81002 | Urinalysis, dipstick | $6-$8 |
| 93000 | ECG with interp | $20-$25 |
| 36415 | Venipuncture | $4-$6 |
Quick Tip: Use Modifier 59 when billing two procedures that might otherwise be bundled—only if they’re distinct.
2. ICD-10 Cheat Sheet for Urgent Care
These are the diagnosis codes that appear again and again in urgent care visits, and must be matched carefully to CPTs for medical necessity.
Common ICD-10 Codes for 2025:
| ICD-10 Code | Description | Matches CPT Codes like |
| J06.9 | Acute URI, unspecified | 99213, 87880 |
| R50.9 | Fever, unspecified | 99213, 96372 |
| J02.9 | Pharyngitis, unspecified | 99203, 87880 |
| S61.012A | Laceration without foreign body (hand | 12001 |
| R10.84 | Generalized abdominal pain | 99203, 99214 |
| M25.561 | Pain in the right knee | 20610 |
Documentation Reminder: ICD-10 specificity matters. Use laterality (right/left), initial vs. subsequent encounter, and injury cause codes when needed.
3. Billing Workflow Optimization for 2025
Here’s how your front desk, providers, and billing team can work together to minimize denials and boost cash flow.
Daily Workflow Tips:
- Front Desk: Collect full insurance data, verify eligibility, and input correct POS (usually 20).
- Provider: Select E/M level based on time or medical decision-making. Document injections, test interpretations, and procedures separately.
- Coder/Biller: Review for Modifier 25/59 accuracy, double-check ICD-CPT linkage, and ensure labs are CLIA-certified.
- Claims Submissions: Batch by payer if possible. Use claim scrubbing software to catch errors before they go out.
- Follow-Up: Track denials, categorize by payer or error type, and review with the billing team monthly.
Hack: Automate claim status checks using your clearinghouse or EHR tools—this drastically reduces follow-up lag.
4. Revenue Cycle Management (RCM) Hacks for Urgent Care
RCM isn’t just back-end—it starts the moment the patient books an appointment.
Tips to Tighten Your RCM in 2025:
- Automate insurance verification before the visit.
- Get pre-authorization tools built into your EHR (especially for Medicaid).
- Reconcile EOBs daily—don’t let one underpaid claim slide.
- Track KPIs monthly:
- First-pass clean claim rate
- Denial rate by code/payer
- Average reimbursement per encounter
- Days in A/R
Pro Tip: Build a Billing SOP (Standard Operating Procedure)
Every urgent care should have a 10–20 page SOP with:
- Common CPT-ICD pairings
- Modifiers by payer
- Telehealth rules by state
- Lab bundling rules
- Rejection fix templates
Why it matters: It reduces onboarding time, prevents knowledge loss, and improves accuracy, especially when hiring new coders or expanding to multiple locations.
Urgent Care Billing in 2025: Case Studies, FAQs & Your Roadmap to Success
1. Real-World Billing Case Studies
Case 1: Adult Patient with Laceration and Tetanus Shot
Scenario:
A 35-year-old male visits for a 2.5 cm forearm laceration after a bike fall. The provider performs a simple wound repair and administers a tetanus shot.
Correct Billing:
| Service | Code | Notes |
| E/M Visit (est. patient) | 99213-25 | Use modifier 25 with the procedure |
| Simple repair | 12001 | Laceration < 2.5cm |
| Tetanus toxoid injection | 90714 | Vaccine CPT |
| Admin of vaccine | 90471 | Must be billed separately |
| Dx Code | S51.811A | Open wound, forearm, initial encounter |
| POS | 20 | Urgent care setting |
Reminder: Always pair the vaccine code (90714) with the admin code (90471). They are not automatically bundled.
Case 2: Virtual Visit for Cough and Fever
Scenario:
A 27-year-old female books a telehealth visit for a non-productive cough and low-grade fever. The provider spends 15 minutes on the call, orders COVID-19 testing.
Correct Billing:
| Service | Code | Notes |
| Telehealth E/M | 99442-95 | 11-20 mins phone consult, use 95 |
| POS | 10 | Indicates patient’s home |
| Dx Code | R05, R50.9 | Cough+ fever |
Pro Tip: 99442 pays ~$55–$65 depending on payer. Make sure audio-only visits are clearly documented as such in the note.
Frequently Asked Questions (FAQs)
Q1. Should we use Modifier 25 on every E/M with a procedure?
A: Only if the E/M is separately identifiable from the procedure. Overuse of Modifier 25 is one of the top audit triggers in 2025. Document clearly why the E/M was needed.
Q2. Is POS 20 still valid for urgent care in 2025?
A: Yes. Most payers recognize POS 20 for urgent care facilities. But POS 10 is now preferred for telehealth from home visits.
Q3. Can we bill for rapid COVID-19 tests in urgent care?
A: Yes, using CPT 87426 for antigen tests and U0003/U0005 for certain high-throughput testing. Ensure you list a medically necessary Dx like Z20.822 (COVID exposure) or R05 (cough).
Q4. Are there reimbursement changes for lab tests in 2025?
A: Yes. CMS has reduced payments for some routine labs, and many are bundled into the visit unless Modifier 91 (repeat test) or CLIA certificate is present.
Q5. What is the clean claim submission rate we should aim for?
A: Best-in-class urgent care clinics maintain a 98%+ clean claim rate on first submission. Use pre-claim scrubbers to hit this benchmark.
3. Urgent Care Billing in 2025: A Winning Strategy
Billing in urgent care is no longer just about fee schedules—it’s a strategic function. It impacts patient satisfaction, provider morale, and your bottom line.
Here’s your 2025 checklist for billing excellence:
- Stay updated on payer policies quarterly
- Keep cheat sheets of high-volume codes visible
- Use accurate POS and modifiers (20, 10, 25, 59)
- Integrate AI claim scrubbers and denial tracking tools
- Monitor RVU and reimbursement trends monthly
- Invest in coder education + SOP documentation
- Audit provider documentation—not just billing
Final Thoughts: The Urgent Care Coder is the Unsung Hero
In 2025, the urgent care coder isn’t just punching in codes—they’re steering the financial health of the clinic. Every denied claim you prevent, every modifier you add correctly, and every missed opportunity you catch make a real impact.
So whether you’re a provider learning to document smarter, a billing manager building processes, or a front-desk rep verifying coverage, you’re part of the revenue engine.
Keep learning. Stay sharp. And don’t just bill—win at it. In order to get detailed and updated information about medical coding and billing, go through other articles on the website, and don’t forget to call “Medstar Billing Services” to get a hundred percent accurate reimbursement for your services.
