Q.We are in the process of adding urgent care services to our occupational medicine clinic. How do we determine when to use a new or established E/M code for the patients who are seen for urgent care services?

A.I continue to receive questions regarding the “when to code new or established patient E&M codes” conundrum, so let’s try to simplify the issue.

The official CPT definition of new patient is: A patient who has not received professional services from a physician or another physician of the same specialty in the same practice within the past three years. [Emphasis added.]

One problem with this definition is that the scope of professional services that counts here is defined differently by the American Medical Association and the Centers for Medicare & Medicaid Services:

  • AMA (i.e., CPT): includes any “professional services” as establishing a patient.
  • CMS: limits these services to face-to-face E/M services.

Figure 1 shows how to use the CMS algorithm to determine if a patient is a new or established patient.

Figure 1. New vs. established patient: CMS Algorithm

Figure 2 shows how to use the AMA algorithm to determine if a patient is a new or established patient.
Figure 2. New vs. established patient: AMA Algorithm

Many practices have chosen to use the CMS definition for all payors, but a particular payor may insist on the AMA rules.

The big question for your practice when making this conversion is this: Will you count occupational medicine visits toward establishing patients in the urgent care?

The simplest (but not necessarily the most profitable) way to answer this is this: If the patient has been seen in the urgent care or occupational medicine clinic in the past three years (not counting drug screens), then the patient is established.

If the urgent care and the occupational medicine clinics are incorporated separately, you may be able to count most new patient visits to the urgent care center as new patients, even if the patient has been previously seen in the occupational medicine clinic.

One exception must always be considered: If the patient has been seen for evaluation and management by the same physician (whether it be in a private practice, emergency department, occupational medicine clinic, or any other setting), then for three subsequent years the patient is an established patient for that particular physician in any practice setting.

Note: CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining legal advice.

Determining New vs. Established Patients for E/M Coding
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