Urgent care facilities play a vital role in the healthcare ecosystem, providing convenient access to medical care for non-life-threatening conditions. To ensure proper reimbursement for services provided in urgent care settings, it’s essential to use appropriate modifiers on claims. We list the most common modifiers used in urgent care billing and provide guidelines for their application.
Common Urgent Care Modifiers
Modifier 25: Significant, Separately Identifiable E/M Service
Description: Used when a provider performs a significant, separately identifiable evaluation and management (E/M) service on the same day as another procedure or service.
Application in Urgent Care: Perhaps the most frequently used modifier in urgent care settings. It allows providers to bill for both an E/M service and a procedure performed during the same visit.
Example: A patient presents to urgent care with a laceration. The provider performs a comprehensive assessment of the wound and patient’s overall condition (E/M service) before proceeding with wound repair (procedure). The E/M code would be appended with modifier 25, and the laceration repair would be billed separately.
Documentation Tips:
- Clearly document the elements of the E/M service separate from the procedure
- Ensure the documentation supports the medical necessity of both services
- Record specific details about what made the E/M service significant and separate
Common Pitfalls:
- Overuse without proper documentation
- Applying when the E/M service is inherent to the procedure
- Failing to meet the “significant and separate” threshold
Modifier GP: Services Delivered Under an Outpatient Physical Therapy Plan of Care
Description: Indicates that physical therapy services were provided under an outpatient physical therapy plan of care.
Application in Urgent Care: Used when physical therapy services are provided in an urgent care setting, particularly for musculoskeletal injuries.
Example: A patient with an acute ankle sprain receives initial physical therapy instruction for home exercises after assessment.
Documentation Tips:
- Document the specific physical therapy services provided
- Include details about the therapy plan
- Note the expected duration and goals of therapy
Modifier GN: Services Delivered Under an Outpatient Speech-Language Pathology Plan of Care
Description: Indicates speech-language pathology services delivered under an outpatient speech-language pathology plan of care.
Application in Urgent Care: Less common but may be used when initial speech therapy services are provided to patients with conditions affecting speech, such as post-concussion syndrome.
Documentation Tips:
- Document the specific speech therapy assessment and services
- Include details about the therapy plan
- Note any referrals for continued speech therapy
Modifier 59: Distinct Procedural Service
Description: Indicates that a procedure or service was distinct from other services performed on the same day and not normally bundled together.
Application in Urgent Care: Used when multiple procedures are performed that would typically be bundled but were performed on different anatomical sites or at different sessions.
Example: A patient presents with both a finger laceration and an unrelated abscess on the leg. The provider performs suturing on the finger and incision and drainage on the leg abscess. Modifier 59 would indicate these were separate procedures.
Documentation Tips:
- Clearly document each procedure separately
- Note different anatomical sites or separate encounters
- Provide medical justification for each procedure
Common Pitfalls:
- Using as a “default” unbundling modifier without justification
- Failing to document distinct nature of procedures
- Using when a more specific modifier (XE, XP, XS, XU) would be more appropriate
X Modifiers (XE, XP, XS, XU): Subsets of Modifier 59
Description: More specific versions of modifier 59 introduced to reduce improper use:
- XE: Separate encounter
- XP: Separate practitioner
- XS: Separate structure or organ system
- XU: Unusual non-overlapping service
Application in Urgent Care: These modifiers provide more precise information about why services should not be bundled.
Example: For the previous example with the finger laceration and leg abscess, modifier XS would be more appropriate than 59, indicating separate anatomical structures.
Documentation Tips:
- Use the most specific X modifier applicable
- Document clear justification for the modifier
- Include details that support the specific X modifier chosen
Modifier 76: Repeat Procedure by Same Physician
Description: Indicates that a procedure or service was repeated by the same physician on the same day.
Application in Urgent Care: Used when a procedure must be repeated due to technical factors or patient needs.
Example: A patient requires a second X-ray of the same anatomical site after the first images were inadequate for diagnosis.
Documentation Tips:
- Document the medical necessity for repeating the procedure
- Note the time of each procedure
- Explain why the repeated procedure was necessary
Modifier 77: Repeat Procedure by Another Physician
Description: Indicates that a procedure was repeated by a different physician on the same day.
Application in Urgent Care: Used when a different provider repeats a procedure previously performed by another provider.
Example: A second provider repeats an ECG due to questions about the initial findings.
Documentation Tips:
- Document why the procedure needed to be repeated
- Note the name of the provider who performed the initial procedure
- Explain the medical necessity for repeating the procedure
Modifier AQ: Physician Providing a Service in an HPSA
Description: Indicates a physician provided a service in a Health Professional Shortage Area (HPSA).
Application in Urgent Care: Used for urgent care facilities located in designated HPSAs.
Documentation Tips:
- Verify the HPSA designation of the facility
- Keep documentation of the HPSA status on file
- Update as HPSA designations change
Modifier CS: Cost-sharing Waived
Description: Indicates cost-sharing is waived for specific COVID-19-related services.
Application in Urgent Care: Used for COVID-19 testing and related services where cost-sharing is waived under specific payer policies.
Documentation Tips:
- Document COVID-19-related nature of the service
- Note applicable waiver programs
- Keep up-to-date with changing policies regarding COVID-19 billing
Modifier GT: Via Interactive Audio and Video Telecommunications System
Description: Indicates services were provided via telehealth.
Application in Urgent Care: Used when urgent care providers deliver services via telehealth platforms.
Example: A patient receives a virtual urgent care consultation for a non-emergency condition.
Documentation Tips:
- Document the telehealth platform used
- Note start and end times of the telehealth session
- Document patient consent for telehealth services
- Record patient location during the telehealth visit
Modifier 95: Synchronous Telemedicine Service
Description: Similar to GT, indicates that services were rendered via real-time interactive audio and video telecommunications.
Application in Urgent Care: Used with CPT codes listed in Appendix P for telehealth services.
Documentation Tips:
- Similar to GT modifier
- Verify the CPT code is eligible for the 95 modifier
- Document the telehealth technology used
Modifier GQ: Via Asynchronous Telecommunications System
Description: Indicates services were provided via asynchronous telecommunications systems (store and forward).
Application in Urgent Care: Used for asynchronous telehealth services where information is collected and sent to a provider for review at a later time.
Example: A patient uploads images of a rash which are later reviewed by an urgent care provider who then provides treatment recommendations.
Documentation Tips:
- Document when the information was received
- Note when the provider reviewed the information
- Record the method of communication with the patient
Modifier CR: Catastrophe/Disaster Related
Description: Indicates that a service is related to a federally declared disaster or emergency.
Application in Urgent Care: Used during declared emergencies such as natural disasters, pandemics, or other public health emergencies.
Documentation Tips:
- Document the specific emergency or disaster
- Note how the service relates to the emergency
- Keep records of the declared emergency dates
After-Hours Modifiers
Modifier 99: Multiple Modifiers
Description: Indicates that more than one modifier applies to a procedure code and there isn’t space to list them all individually.
Application in Urgent Care: Used when multiple circumstances apply to a single service.
Documentation Tips:
- Document all applicable modifiers in the notes
- Ensure documentation supports each modifier used
- List the modifiers in descending order of impact on reimbursement
Time-Based Modifiers
Modifier FP: Service Provided as Part of Family Planning Program
Description: Indicates a service was provided as part of a family planning program.
Application in Urgent Care: Used when family planning services are provided in an urgent care setting.
Documentation Tips:
- Document the specific family planning service provided
- Note the family planning program involved
- Ensure patient consent is documented
Modifier 32: Mandated Services
Description: Indicates a service was mandated by a third party, such as an employer or court.
Application in Urgent Care: Used for services like drug screens or physical exams required by employers.
Example: A pre-employment physical examination required by an employer.
Documentation Tips:
- Document the mandating entity
- Note the specific requirements of the mandated service
- Maintain a copy of the mandate if possible
Modifier 50: Bilateral Procedure
Description: Indicates a procedure was performed on both sides of the body.
Application in Urgent Care: Used when identical procedures are performed on paired organs or body parts.
Example: X-rays taken of both wrists after a fall.
Documentation Tips:
- Clearly document that the procedure was performed bilaterally
- Note findings for each side separately
- Follow payer-specific guidelines for reporting bilateral procedures
Modifier 52: Reduced Services
Description: Indicates a service or procedure was partially reduced or eliminated.
Application in Urgent Care: Used when a procedure was started but discontinued for some reason.
Example: A laceration repair that was less extensive than the full procedure described by the CPT code.
Documentation Tips:
- Document why the service was reduced
- Describe what portion of the service was completed
- Note any plans for completing the service later
Modifier 53: Discontinued Procedure
Description: Indicates a procedure was started but discontinued due to patient safety concerns.
Application in Urgent Care: Used when a procedure must be stopped due to patient distress or safety concerns.
Example: An incision and drainage procedure stopped due to patient experiencing severe pain or adverse reaction.
Documentation Tips:
- Document the exact reason for discontinuation
- Note how much of the procedure was completed
- Record the patient’s condition after discontinuation
- Document any follow-up plans
Best Practices for Modifier Usage in Urgent Care
- Review Documentation Before Coding: Ensure the medical record contains sufficient documentation to support modifier usage.
- Stay Current with Guidelines: Regularly review coding guidelines, payer policies, and modifier updates.
- Implement Internal Audits: Conduct regular audits of modifier usage to identify patterns of incorrect application.
- Provide Staff Education: Train billing staff and providers on proper modifier usage specific to urgent care settings.
- Develop a Modifier Cheat Sheet: Create a quick reference guide for commonly used modifiers in your facility.
- Monitor Denials: Track claim denials related to modifiers and address recurring issues.
- Consider Payer Preferences: Be aware that different payers may have different requirements for modifier usage.
- Document Medical Necessity: Always ensure documentation supports the medical necessity of services provided and the modifiers applied.
Common Audit Findings Related to Modifiers in Urgent Care
- Inappropriate Use of Modifier 25: Applying modifier 25 when the E/M service is not significant or separately identifiable.
- Overuse of Modifier 59: Using modifier 59 as a general unbundling tool without proper justification.
- Incorrect Application of X Modifiers: Failing to use the most specific X modifier when applicable.
- Missing Documentation for Modifiers: Applying modifiers without supporting documentation.
- Double Dipping with Modifiers: Applying multiple modifiers that serve the same purpose or contradict each other.
Summary: Urgent Care Modifiers and Their Usage
Proper use of modifiers in urgent care billing is essential for accurate coding, appropriate reimbursement, and compliance with coding guidelines. When urgent care centers master these modifiers and implement proper documentation practices, they not only improve their reimbursement rates but also reduce compliance risks and audit exposure.
Regular training, auditing, and staying current with coding updates will help ensure that modifiers are used appropriately. Payer requirements and coding guidelines change frequently, so staying current through regular training and updates is crucial for your billing team’s effectiveness.
References
- American Medical Association. (2024). Current Procedural Terminology (CPT) Professional Edition.
- Centers for Medicare & Medicaid Services. (2024). HCPCS Level II Coding Manual.
- American Academy of Professional Coders. (2024). Coding Guidelines for Urgent Care.
- Urgent Care Association. (2025). Billing and Coding Handbook for Urgent Care Centers.
- Centers for Medicare & Medicaid Services. (2024). Medicare Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners.
Note: This article is for informational purposes only and does not constitute professional coding advice. Always consult official coding resources and payer policies for specific guidance.
