CODING Q&A The Finer Points in Determining New vs. Established Patients ■ DAVID STERN, MD, CPC Q . Our urgent care practice serves a 70-physician pri- mary care group. The UC uses the three-year rule; if the patient has been seen by any physician in the medical group within the last three years, he/she is an established pa- tient—even if the patient has never been previously seen in the urgent care. A comparable UC center in a nearby city ap- plies the three-year rule differently; if the patient has been seen in the urgent care within the last three years, he/she is an established patient. The urgent care center does not count visits to a physician in the medical group. Can you tell me who is correct? Urgent Care Physician, California According to CPT, a “new” patient is a patient “who has not received any professional services* from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” The definition sounds quite simple, but the application is quite complex. For a patient presenting to this urgent care center for the first time in the past three years, several different scenarios might apply: A. Established Patient Scenario A: Code as an established patient (no exceptions) if the urgent care physician has performed professional services on the patient in the past three years in any setting—urgent care, physician practice, hospital, hospital emergency depart- ment, nursing home, or any other place of service. Scenario B: Code as an established patient: David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at dstern@practicevelocity.com. w w w. j u c m . c o m 1. if the urgent care physician is a member of the same primary care group practice 2. and the physician (who has seen the patient in the group practice) practices the same specialty as the ur- gent care physician. New Patient Scenario A: You may code as a new patient: 1. if the urgent care is a separate business (operating un- der a separate TIN) from the group practice 2. and the urgent care physician is not a member of the primary care practice. Scenario B: You may code as a new patient: 1. if the urgent care operates under the same TIN or a different TIN (it makes no difference) as the group practice 2. and the urgent care physician is a member of the group practice 3. and the urgent care physician has never performed professional services on the patient 4. and the patient has been seen in the group practice, but the physician who performed professional services in the group practice is of a different specialty than any physician who has performed professional services on the patient. Stand-Alone Urgent Care For an urgent care center that is not affiliated with a group practice, a corollary of the above explanation is that an ur- gent care center can code any patient as a new patient if that patient is being seen by a physician who is of a different spe- cialty than any other physician who has already seen the pa- tient in the urgent care center. Several payors (but not all payors queried) have person- ally communicated to me that they find this coding method perfectly acceptable. Example: A patient has been seen multiple times in the ur- JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | A p r i l 2 0 0 8 41