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The big news this month is a welcome announcement for urgent care vaccine sites. Effective March 15, 2021, the Centers for Medicare & Medicaid Services (CMS) increased the fee for administering the COVID-19 vaccine to $40 per dose. As the pandemic continues, COVID-19 vaccinations may become an important part of the urgent care business. It’s a good time to assess whether vaccine administration is a fit for your clinic. With a little more pandemic breathing room, it’s also a good time for urgent care clinics to take a step back and review some basics.

In this month’s “3 Things to Know About RCM,” we’ll provide information about the increases in vaccination reimbursement, share helpful resources for vaccination administration and planning, and review some important coding guidelines and changes.

Higher Reimbursement for COVID-19 Vaccine Administration

Considering the low reimbursement for vaccination administration, many urgent care owners and operators were asking themselves whether to opt out or meet the demand for COVID-19 vaccines for their patients and their communities.

Higher reimbursement is one factor worth considering when facing this decision. The newly announced Medicare payment of $40 — an increase of $34.67 for vaccines that require two doses and $11.61 for vaccines with a single dose — will make this choice a little easier. The COVID-19 Uninsured Program reimburses at Medicare rates. Insurance payers are expected to follow suit.

The vaccine itself is provided free-of-charge to the provider. The administration fee is the only billable service for these encounters. Each unique vaccine has its own administration code (s), depending on the number of doses.

Vaccine Administration Manufacturer
0001A (1st dose)
0002A (2nd dose)
Pfizer, Inc.
0011A (1st dose)
0012A (2nd dose)
Moderna, Inc.
0021A (1st dose)
0022A (2nd dose)
AstraZeneca, Plc.
0031A (single dose) Janssen (Johnson & Johnson)

Remember: When the sole purpose of the visit is to administer the vaccine, an evaluation and management (E/M) visit should not be reported separately. CPT 99211 (i.e., a minimal visit) captures the same services as the vaccine administration codes (0001A-0031A). Only the vaccine administration should be billed. All vaccines are reported with diagnosis code Z23 (Encounter for immunization).

Use these resources as a foundation for your vaccination rollout

Not sure about the best processes and protocols for offering COVID-19 vaccinations at your urgent care clinic? Since clinics across the country joined in the vaccination effort, federal agencies and healthcare organizations began creating resources to make it easier — and they’re free. Take a look at these resources to answer your questions about vaccinations, address staff concerns, and get advice on advising patients.

  1. Medicare: Several Centers for Medicare & Medicaid Services (CMS) toolkits offer guidance for healthcare providers ramping up their vaccination plans. The agency toolkits provide Medicare-specific COVID-19 vaccination guidance on enrollment and billing for shot administration; coding, billing, and reimbursement for COVID-19 shots; beneficiary incentives; quality reporting; SNF enforcement discretion for pharmacy immunizers; and COVID-19 therapies and subsequent add-on payments. Access the Medicare toolkits.
  2. CDC: The Centers for Disease Control and Prevention (CDC) offers its own vault of vaccination information for clinicians, essential workers, and community-based organizations.
  3. ONC: If you’re looking for a plethora of health IT advice all in one place, then the HHS Office of the National Coordinator for Information Technology (ONC) COVID-19 response page is the answer. Examine the various options, including insight on data collecting, cybersecurity, testing, tracking, and more.
  4. FDA: The U.S. Food and Drug Administration (FDA) delves deeply into the nuances of the COVID-19 vaccines with scientific and health perspectives to allay provider, patient, and industry concerns. See a mix of fact sheets, FAQs, videos, and more on topics like vaccine basics, research and future vaccines, the emergency use authorization (EUA) process, and healthcare tips.
  5. Clinician organizations: Many professional groups have created reference guides on the COVID-19 vaccines. Two of the biggest, the AMA and the American Nurses Association (ANA), offer clinicians advice on shot administration, patient engagement, ethics, health equity, liability, mental health, and staffing. AMA resources and ANA resources are helpful guides for your team..

Reminder: Though the Biden administration recommends how the vaccines should be dispensed and administered, those final decisions are up to the states — and each one is handling it differently. State tools vary, but most include vaccine management and registration advice, including dashboards with modules, FAQs, patient engagement tips, graphics, inventory, IT assistance, and facility-specific insight. Bottom line: Check with your state.

Essential urgent care coding tips – a refresher

Some ED practices have expanded to include urgent care center (UCC) ownership, but coding for these services can be vastly different from coding in the ED setting.

Urgent Care Centers (UCCs) are generally equipped to treat non-life-threatening acute injuries and illnesses that do not require hospital admission. Most UCCs also provide other non-emergent services such as prescription refills, sports/school physicals, occupational health services, vaccinations, and STD testing. And lately, UCCs have become some of the most common sites for COVID-19 test administrations. These tips will help you code with accuracy.

1. Use Office E/M Codes for Services Outside the ED

To code and bill E/M services in the urgent care setting, you will use the Office or Other Outpatient E/M codes. The CPT® code ranges for these E/M codes are 99202-99205 for new patients and 99211-99215 for established patients.

CPT® defines a new patient as one “who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” Therefore, if a patient sees Physician A (an ED provider) in the UCC setting in 2020 and returns in March 2021 to see Physician B (another ED provider), then that would be considered an established patient. Of note: This is different from how it would be in the ED setting, because the ED E/M code set (99281-99285) does not differentiate between new and established patients.

2. Zero in on These Key E/M Component Differences

Coders whose experience is mainly with ED E/M codes 99281-99285 should carefully review the CPT® guidelines for coding the outpatient E/M codes, as there are some differences — and the guidance for these codes just changed in January 2021.

First: You can choose to report the appropriate code (99202- 99215) based on medical decision making (MDM) or on time alone whether you meet the old requirement that counseling and/or coordination of care dominates the service.

Second: The number of minutes included in the code descriptors changes for each code in the 99202-99215 range in 2021. Additionally, prior to January, time was used as a “typical” time. Instead, CPT® 2021 lists a total time range for each code.

Third: You should select your code level based on time or the MDM — you don’t need both. Total time could include face-to-face time, as well as time spent reviewing the chart before the encounter, time ordering diagnostics, coordinating care after the encounter, or even writing documentation — but not time spent by non-billable staff. A table with the time thresholds appears below:

E/M code selection based on time

New Patient Established Patient
99201 Deleted 99211 Nurse visit
99202 15-29 minutes 99212 10-19 minutes
99203 30-44 minutes 99213 20-29 minutes
99204 45-59 minutes 99214 30-39 minutes
99205 60-74 minutes 99215 40-54 minutes
For services 75 minutes or longer, see prolonged services code +99417 For services 75 minutes or longer, see prolonged services code +99417

Remember: The medical record must reflect the provider’s actions during each encounter.

3. Don’t Forget the POS Code is Different, too

Place of service for urgent care services can vary according to the payer guidelines and the specific characteristics of the UCC, so watch how you apply your POS indicator.

You will use place of service (POS) codes 11 (Office), 20 (Urgent care facility), or 22 (On-campus outpatient hospital) as follows:

  • POS 20 is specifically for urgent care facilities defined by CPT® as a location distinct from a hospital ED, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
  • POS 22 is for an outpatient hospital.
  • POS 11 is for an office location other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, public health clinic, or intermediate care facility where the healthcare profes­sional provides routine health examinations, and diagnosis and treatment of illness or injury on a routine basis.

Interested in more urgent care tips, best practices, and industry updates? Check out our February and March installments on Urgent Care Guidance on Provider Relief, Telehealth Expansion, and COVID Vaccines and Tips for Navigating Telehealth Expansion and Reimbursement.

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