Urgent Care 2026: How CPT & CMS Changes Hit Your A/R and Denials

January 2026 brought a set of CPT and CMS changes that look small on paper but show up fast in urgent care AR. Nine months in, many billing teams are still finding claims held up, underpaid, or at risk of recoupment. Here is what changed, what still breaks in the revenue cycle, and a question for you at the end.

This article will cover:

• The combo test change: 87811, 87804, and 87812
• Other coding changes worth checking
• The 2.5% efficiency adjustment
• Higher Medicare Part B premiums and deductibles
• Workers’ comp changes for work-related injuries
• What we are seeing in AR
• What to do next
• Over to you

The combo test change: 87811, 87804, and 87812

Since January 1, 2026, visually read COVID-19 and Influenza A/B combination tests are reported with one code, 87812, instead of 87811 plus 87804. That covers common kits such as BinaxNOW COVID-19/Flu A&B and Flowflex Plus. 87811 and 87804 remain valid when you test for COVID only or flu only.

The catch is timing. Some payers kept paying the old pair at 2025 rates while their systems caught up. Those claims may look settled today and still be reviewed later. Payers that updated early may reject the old pair outright. If your chargemaster still defaults to the pair, you are either leaving denials on the table or inviting a future takeback.

Other coding changes worth checking

A few more 2026 codes belong on your urgent care audit list:

• 87494 for combined chlamydia and gonorrhea amplified probe tests.
• 90481, a COVID-19 vaccine administration add-on, plus time-based counseling codes 90482–90484 for when the vaccine is not given the same day.

Confirm each is live in your EMR, mapped to the right fee schedule, and recognized by your top payers before you treat mix-ups as one-off denials.

The 2.5% efficiency adjustment

The 2026 Medicare Physician Fee Schedule cut work RVUs by 2.5% on nearly all non-time-based codes: procedures, imaging, and diagnostic tests. Time-based E/M office visits are exempt.

The conversion factor rose about 3.26%, to $33.4009 for most practitioners. For procedure-heavy urgent care visits, though—laceration repairs, splinting, incision and drainage, and X-rays—the RVU cut takes back much of that gain.

Because the cut sits in the RVUs, commercial and workers’ comp payers that price off the Medicare RVU table can pass it on too. Compare 2026 payments on your high-volume procedure codes against 2025 contracted rates. If the line paid but paid less than you budgeted, that is still a revenue problem.

Higher Medicare Part B premiums and deductibles

The standard Part B premium rose to $202.90 a month, up from $185.00. The annual deductible rose to $283, up from $257.

For urgent care, that means more early-year visits land inside the deductible, and more of each visit becomes patient balance, with 20% coinsurance after that. Real-time eligibility checks that show the remaining deductible, clear estimates, and collection at the time of service matter more than ever. Soft balances that wait for a statement after the visit grow when deductibles reset this hard.

Workers’ comp changes for work-related injuries

California: The DWC updated its physician fee schedule for dates of service on or after March 1, 2026, including higher rates for California-specific report codes such as WC002 for PR-2 progress reports. Bills priced at old rates, or missing report codes, leave money behind.

New York: The Workers’ Compensation Board proposed a medical fee schedule update, first published in January 2026 and revised in August 2026, with increases aimed at non-procedural ambulatory visits. CMS-1500 electronic submission is also mandatory.

Everywhere else: Many state WC fee schedules are built on Medicare RBRVS, so the RVU cut and new codes like 87812 flow into WC pricing on each state’s own timeline.

Common urgent care WC denials still come from the basics: a missing claim number or employer authorization, the wrong state fee schedule applied, or required reports not attached. Coding updates do not fix a broken authorization trail.

What we are seeing in AR

The patterns are familiar:

• Unbundling denials on combo tests
• Procedure lines paying below expected after the RVU change
• Patient balances growing as deductibles reset
• WC bills paid at last year’s state rates

Several of these never show up as denials, because the claim technically paid. That is why a paid-but-underpaid look-back beats waiting for a rejection queue to tell you something is wrong.

What to do next

Start with a chargemaster update in the EMR so 87812, 87494, and the vaccine codes are the default where they belong. Next, run a targeted look-back at claims since January, sorted by payer, code, and status. Last, keep a short payer-by-payer tracker so the team knows who accepts 87812 today and who still needs follow-up, rebilling, or an appeal.

Over to you

Are you still seeing claims stuck on any of these changes? Which payers have been slowest to update, and how is your team handling it: holding claims, rebilling, appealing, or waiting on payer guidance?