Revenue Leakage due to coding errors in Urgent Care Centers

By: exdionrcm


Recent report by Urgent Care Association (UCA) in United States indicate that about 89 million patients visit Urgent Care Centres for treatment annually. The industry is expected to reach $26 billion by 2023. The 2018 Urgent Care Benchmark survey response indicate only 7% of total patients were of the fully cash pay category. 93% users had some form of insurance or other coverage which reflects the importance for high level of billing accuracy and automation of operations. With 8774 centres operating nationwide, and centres openings every day, staff members responsible for coding medical instances, eliminating coding errors and inefficiencies is paramount to their financial success.

The difference between insufficient and erroneous coding is in the former, the urgent care centre does not bill for all services consumed by the patient while the latter is when wrong code has been used while billing. Figure 1 presents revenue leakages due to insufficient and incorrect coding. A coding insufficiency is noticed by the insurance payer when there is a gap in match between services provided and billed. The American  Medical Association (AMA) updates the CPT annually and service providers need to ensure the codes used are relevant and audited. Also visit pattern has to be considered while posting a code against services consumed at the Urgent Care Centre. Let us consider an example case for inefficiencies in coding. A pregnant visitor from out of town in her first trimester visits an urgent care centre to measure blood pressure, weight & manage morning sickness adhoc. This could be a service extended by a nurse practitioner and not something the insurance company might reimburse. However, a gestational diabetes screening or anomalies scan in Trimester two would involve a set of blood draws/ tests/scans being ordered. So while coding and for purpose of billing, care should be taken to sufficiently record all procedures conducted in order to ensure bills submitted to carriers or payers are accurate . This will result in lesser claims being rejected.

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