DAVID STERN, MD (Practice Velocity)
Q.Our urgent care practice serves a 70-physician primary 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 patient even if the patient has never been previously seen in the urgent care. A comparable UC center in a nearby city applies 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 A.
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:

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 department, nursing home, or any other place of service.

Scenario B: Code as an established patient:

  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

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

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

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 urgent care center can code any patient as a new patient if that patient is being seen by a physician who is of a different specialty than any other physician who has already seen the patient in the urgent care center.
Several payors (but not all payors queried) have personally communicated to me that they find this coding method perfectly acceptable.

Example: A patient has been seen multiple times in the urgent care center by internists, by family practice physicians, and by pediatricians. Today, the patient is being seen by a physician who specializes in emergency medicine. Even though the patient has been seen multiple times in the urgent care center, you could code this patient as a new patient.

 
Arguments Against Such Implementation
Although these creative methods for coding new patient visits are compliant, there are arguments to be made against using them, as follows:

  • Every patient must be established by practice, physi- cian, and by specialty of physician. This presents sig- nificant tracking difficulties in maintaining and up- dating such a complex
  • Since some physicians may actually be board eligible or board certified in more than one specialty, a patient may become “established” in the urgent care for two or three specialties when receiving an encounter with a single
  • Many payors may find these coding methods inappropriate and may seek to recover so-called “overpayments” for many previous
  • Coding separately for every different specialty represented in an urgent care seems to contradict the contention of organized urgent care medicine that urgent care physicians are practicing a unique When a physician is practicing in an urgent care setting, she is not practicing internal medicine, family practice, or some other specialty; she is practicing urgent care medicine.
  • It is hoped that at some point in the future legitimate board certification in urgent care might be established and recognized by the larger community of organized medicine.
  • Patients who have been seen multiple times in the ur- gent care practice may not be happy to be classified, coded, and billed as new
  • These methods may follow the letter of regulations, but they do not seem to fall within the intent of the regulations on new and established

Thus, my personal recommendations are these:

  • If a patient has received professional services from any physician of any specialty in the urgent care, then subsequent visits within a three-year time frame may be coded as established patient
  • If the urgent care has the same ownership as a group practice, and the same physicians may see patients in either the group practice or the urgent care, then patient visits may be coded as established if the patient has received professional services from any physician  in either practice.
  • If the urgent care has the same ownership as a practice, and the urgent care center is staffed by completely separate physicians from the group practice, then patient visits should be coded as established if the patient has received professional services in the urgent care center Visits to the group practice are not taken into account.

 
*“Professional Services”: What constitutes professional services has been defined by CPT as “those face-to-face services rendered by a physician and reported by a specific CPT code(s).”
The following services can be reported with a specific CPT code but are not rendered “face-to-face,” so a subsequent face-to-face encounter would be coded as a new patient:

  • Example 1: If the physician reads an EKG on a hospital patient that the physician did not see face-to-face, this would not constitute a “face-to-face” If the patient is seen subsequently for the first time in the urgent care, then the patient visit would be coded as a new patient.
  • Example 2: The physician calls in an antihypertensive medication for a patient who has moved into the com- munity and has a first appointment in a week. When the patient visits the clinic, the visit is coded as a new patient
  • Example 3: The physician sutures a laceration on a patient in a hospital emergency Six months later, the physician sees the patient in an urgent care center. This is an established patient.

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 appropriate legal advice.

The Finer Points in Determining New vs. Established Patients

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine
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