David Stern, MD, CPC
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 urgent
care physician.
New Patient
Scenario A: You may code as a new patient:
1. if the urgent care is a separate business (operating under
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 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, physician,
and by specialty of physician. This presents significant
tracking difficulties in maintaining and updating
such a complex database.
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 physician.
Many payors may find these coding methods inappropriate
and may seek to recover so-called “overpayments”
for many previous years.
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 specialty. 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 urgent
care practice may not be happy to be classified,
coded, and billed as new patients.
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 patients.
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 visits.
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 only. 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” encounter. 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 community
and has a first appointment in a week. When
the patient visits the clinic, the visit is coded as a new
patient visit.
Example 3: The physician sutures a laceration on a patient
in a hospital emergency department. 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.
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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
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