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

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 scrutiny. Practices receive notification letters identifying the providers and codes under review, with claims requiring medical records submission at initial claim filing. Failure to submit leads to claim denials and payment delays. Alarmingly, these reviews are often subjective, with no clear benchmarks for removal, making provider experiences highly variable. 

Post-payment reviews are equally challenging. Often conducted by recovery companies like Cotiviti or MCMC, these audits involve requests for medical records for past services, potentially leading to substantial refund demands. Missteps, such as using outdated 1995 guidelines for claims post-2021, misunderstanding data review requirements, or minimizing the seriousness of conditions like COVID-19, have been cited as common errors. 

When payers demand refunds, they often seek the full claim amount, not just the differential between billed and “corrected” services. Negotiation and counteroffers become vital, particularly when extrapolated repayment demands soar into six-figure territories. 

Accurate Documentation: The Key to Success 

With coding guidelines now focusing heavily on MDM, clear documentation reflecting the scope of problems addressed during visits is critical. Providers must go beyond recording final diagnoses. Documenting the differential diagnosis process, including history, exam findings, and diagnostic reasoning, is essential both for accurate coding and excellent patient care. 

Instituting a formalized education process helps. Appointing a coding champion who liaises between clinicians and billing teams ensures consistent, real-time feedback. Since many providers are unaware of the nuanced changes in coding rules, ongoing education can dramatically reduce pre-payment review occurrences. Moreover, when practices under pre-payment reviews fail to adapt, audits are extended, compounding delays and financial risk. 

Mastering the Language of Medical Decision-Making 

The MDM table in CPT® guidelines can be subjective and confusing, especially regarding terminology under its three main elements: Problems Addressed, Amount and Complexity of Data Reviewed, and Risk of Complications. 

Clarifying Problems Addressed 

Terms like “acute” and “self-limited” cause frequent confusion. “Acute” does not necessarily mean “new” but instead refers to recent or short-term problems, even follow-ups to previously treated conditions. Coders must understand that “self-limited” or “minor” problems are those likely to resolve without medical intervention, like the common cold or minor injuries. 

When it comes to exacerbations, documentation is key. Providers must describe the severity of any worsening conditions to justify higher MDM levels. Without clear notes, coders must assume moderate severity, which can impact appropriate code selection. 

Demystifying Data Review 

The Amount and Complexity of Data Reviewed category is another frequent stumbling block. However, coders should remember that only two out of three MDM elements need to meet a level for code selection. If Problems Addressed and Risk of Complications clearly support a high-level code, intricate calculations around data complexity become unnecessary. 

That said, data element understanding remains important for provider education. Helping providers understand when and how their documentation affects coding accuracy can preempt future review issues. 

Understanding Risk of Complications 

In MDM, “risk” pertains to the treatment plan, not the inherent patient risk. For instance, treating gastroenteritis with over-the-counter medication and home care recommendations constitutes low treatment risk, even if the patient’s symptoms seem serious. Coders must base risk assessment on documented plans, not their own interpretations of patient condition severity. 

The CPT® guidelines clarify that even a low probability of death might still equate to a high-risk classification, depending on the treatment complexity. Therefore, establishing open communication with providers about their clinical thought processes becomes essential. If provider notes do not clearly indicate risk, coders should default to the lowest reasonable risk level to maintain compliance. 

Unique Tests, Independent Historians, and External Discussions 

Additional nuances affect coding accuracy. A “unique test” is defined by a single CPT® code, regardless of the number of times performed. Ordering and reviewing a test counts as a single data point, not two. Independent interpretation of results (not merely review) adds to data complexity but only if the provider isn’t billing for the test themselves. 

Moreover, discussions with external providers — not those within the same group — count toward MDM complexity. Even communication with ER staff regarding a referred patient qualifies. Independent historians, such as parents or caregivers, bolster the documentation in cases where patient history is incomplete, but translators do not fulfill this role. 

Building a Stronger Documentation Culture 

The path to fewer audits and faster reimbursements lies in proactive documentation improvement. Structured provider education, regular feedback loops, and the establishment of a “coding champion” can drive better documentation habits. Urgent care operators who invest in training and robust internal review systems are better positioned to navigate payer scrutiny successfully. 

Ultimately, accurate coding is not merely about revenue. It aligns directly with delivering better patient care and ensures compliance with ever-evolving payer requirements. By demystifying MDM concepts, embracing ongoing education, and fostering provider-coder collaboration, urgent care practices can turn the tide against costly audits and secure their financial and operational future.