M1054 HCPCS Urgent Care Reimbursement | OpenPayer

Summary & Overview

HCPCS M1054: Urgent Care–Only Visits

HCPCS Level II code M1054 denotes patients who had only urgent care visits during the performance period. Nationally, this classification matters because it identifies a population whose care was delivered exclusively through episodic, unscheduled urgent care settings rather than through primary care or specialist outpatient services. That distinction can affect quality measurement, care coordination assessments, and utilization reporting across payer programs.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what the code represents, the clinical and service context (urgent care visits and urgent care clinic sites), and an outline of where this classification intersects with measurement and reporting frameworks. The publication summarizes benchmarks and reporting considerations where available and calls out where data is not provided.

This summary provides national context for policymakers, payers, and provider organizations seeking to understand how exclusive urgent care utilization is captured in administrative reporting and performance measurement. It does not provide clinical recommendations or payer-specific reimbursement details.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1054HCPCS Level IIurgent careutilizationperformance measurementcare coordinationquality reporting

Billing Code Overview

HCPCS Level II code M1054 indicates that the patient had only urgent care visits during the performance period. This code represents a service-type classification used to denote members whose care during the measurement or performance period was limited exclusively to urgent care encounters.

Service type: Urgent care services
Typical site of service: Urgent care clinics or urgent care centers

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

Service: M1054 — Patient had only urgent care visits during the performance period.

A typical scenario involves an adult patient who sought only urgent care services during the measurement or performance period and did not have any primary care or specialty outpatient visits. The patient presents to an urgent care clinic with an acute complaint (for example, upper respiratory infection symptoms, minor laceration, or sprain). The urgent care clinician documents history, exam, and acute diagnosis, provides treatment (medication, wound care, splinting), and issues follow-up instructions. The clinical workflow includes triage, clinician evaluation, point-of-care testing as indicated (e.g., rapid strep, influenza), treatment, documentation of services rendered, and coding/billing indicating that the patient had only urgent care visits for the performance period using billing code M1054.

Typical site of service: Urgent care clinic or freestanding urgent care center.

Typical patient scenario: An adult patient with acute sore throat and fever attends an urgent care clinic, receives rapid influenza testing, symptomatic treatment, and an electronic visit note. No visits to primary care or specialty outpatient clinics occur during the defined performance period; coding reflects that the patient’s only ambulatory encounters were urgent care visits (M1054).

Common payors for coding and quality-reporting contexts: Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, Medicare.

Coding Specifications

HCPCS Level II M1059: Hospice or Palliative Care Status

HCPCS-LEVEL-II-M1022-HOSPICE-ENROLLED-PATIENTS

HCPCS Level II M1022: Patients Enrolled in Hospice During Performance Period

HCPCS-M1009-DISCHARGE-EPISODE-OF-CARE

HCPCS M1009: Discharge/Discontinuation of Episode of Care

HCPCS-M1034-180-DAYS-OPIOID-USE-DISORDER-PHARMACOTHERAPY-CONTINUITY

HCPCS M1034: 180-Day Continuous Pharmacotherapy for Opioid Use Disorder

HCPCS-M1018-CANCER-HISTORY-HEAVY-SMOKER-LUNG-SCREENING

HCPCS M1018: Cancer History, Heavy Smoker, Lung Cancer Screening

HCPCS-M1062-PATIENT-IMMUNOCOMPROMISED

HCPCS M1062: Patient Immunocompromised

HCPCS-M1015-DISCHARGE-EPISODE-OF-CARE

HCPCS Level II M1015: Discharge/Discontinuation of Episode of Care

HCPCS-M1060-PATIENT-DIED-PRIOR-TO-PERFORMANCE-PERIOD

HCPCS M1060: Patient Died Prior to End of Performance Period

HCPCS-M1042-OSWESTRY-DISABILITY-INDEX-PREOP-POSTOP

HCPCS Level II M1042: Oswestry Disability Index Preop and 1-Year Postop

HCPCS-M1047-OXFORD-KNEE-SCORE-PATIENT-REPORTED-OUTCOME

HCPCS Level II M1047: Oxford Knee Score Patient-Reported Outcome

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Most common clinicians in urgent care settings; primary evaluators for acute complaints.
`208D00000X`	Emergency Medicine	Urgent/emergent clinicians who may staff urgent care centers and manage higher-acuity cases.
`363A00000X`	Nurse Practitioner	Advanced practice clinicians who provide evaluation, treatment, and billing in urgent care.
`367A00000X`	Physician Assistant	Common providers performing urgent care visits and procedures.
`207L00000X`	Internal Medicine	May cover urgent care shifts or see patients with acute exacerbations of chronic disease.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`J02.9`	Acute pharyngitis, unspecified	Common urgent care diagnosis for sore throat presentations.
`J11.1`	Influenza with other respiratory manifestations, seasonal influenza virus identified	Frequent acute infectious presentation managed in urgent care with testing and symptomatic treatment.
`S01.81XA`	Laceration without foreign body of other part of head, initial encounter	Typical diagnosis for minor head laceration treated with wound repair in urgent care.
`S93.401A`	Sprain of unspecified ligament of right ankle, initial encounter	Common musculoskeletal complaint evaluated and managed in urgent care, often with splinting and imaging.
`R07.9`	Chest pain, unspecified	Urgent care may evaluate chest pain presentations and determine need for higher-level care or referral.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99202`	Office or other outpatient visit for the evaluation and management of a new patient, typically 15–29 minutes	Common E/M code used in urgent care for new patients presenting with acute complaints.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 20–29 minutes	Common E/M code used in urgent care for return or established patients with acute, uncomplicated problems.
`99051`	Service(s) provided in the evening, weekend, or holiday (list separately in addition to code for basic service)	May be appended for urgent care visits rendered during after-hours.
`99070`	Supplies and materials (e.g., bandages, splints) provided by the physician over and above those usually included with the office visit	Used when supplies are furnished during urgent care treatment (e.g., wound care supplies).
`12001`	Simple repair of superficial wounds of face, ears, eyelids, nose, lips; 2.5 cm or less	Frequently performed in urgent care for minor laceration repair during an urgent visit.
`73140`	Radiologic examination, ankle; complete, minimum two views	Example imaging commonly ordered in urgent care for suspected ankle sprain or fracture.

`22`	Increased procedural services	When work required substantially exceeds typical for the procedure and documentation supports increased work.
`23`	Unusual anesthesia	When general anesthesia is medically necessary and not normally used for the procedure.
`52`	Reduced services	When a service is partially reduced or eliminated at the physician’s discretion.
`53`	Discontinued procedure	When a procedure is started but discontinued due to patient condition or extenuating circumstances.
`54`	Surgical care only	When postoperative management is not provided by the reporting surgeon.
`55`	Postoperative management only	When only postoperative care is provided by the reporting surgeon.
`56`	Preoperative management only	When only preoperative evaluation and management are performed by the reporting clinician.
`62`	Two surgeons	When two surgeons with distinct skills perform the procedure together; each bills with appropriate documentation.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	When an advanced practice clinician provides assistant-at-surgery services and payer accepts `AS`.
`QX`	Certified registered nurse anesthetist (CRNA) service with medical direction by physician	When a CRNA provides anesthesia services under physician medical direction.

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