Alan A. Ayers, MBA, MAcc is Chief Executive Officer of Velocity Urgent Care and is Practice Management Editor of The Journal of Urgent Care Medicine.
Urgent message: While it’s common for urgent care patients to raise multiple medical concerns during an urgent care visit, there is only one “chief complaint”—the potentially most serious of all concerns during that visit.
It’s a frequent occurrence for patients to present in an urgent care center with multiple medical concerns they want a provider to address during their visit. For example, “I have sinusitis and am coughing up phlegm, but I’ve also had this rash on my leg for 6 weeks and my elbow hurt yesterday when I played tennis.”
In addition, sometimes patients who are embarrassed about their medical condition often tell the front office and medical assistants they’re presenting for one condition but when the doctor arrives, they reveal the “true” reason for their visit. For example, the patient may say he has “sinusitis,” but his more pressing issue is the “burn down there.”
From a medical practice perspective, there is only one chief complaint per visit, with all other issues documented through the review of systems. It’s up to the urgent care provider to identify the chief complaint (the most potentially serious of all complaints) and to assess whether the additional complaints are related to the chief compliant or are separate, distinct problems that could be treated on a follow-up visit.
The first consideration should be whether the complaints are related. For example, a patient presenting with a headache, rash, and sore throat may appear as having unrelated complaints, but in taking a systemic approach it could turn out the patient is exhibiting multiple symptoms of a single, more serious condition (eg, meningitis, onset of multiple sclerosis). The role of urgent care when treating patients who will need follow-up or further treatment beyond the urgent care center is to stabilize the patient until they can see the appropriate specialist or primary care provider.
In cases in which the various medical complaints are truly unrelated, whether the provider treats all conditions or refers some conditions to a follow-up visit requires balancing considerations that include the provider’s time availability, payer contracts, and how patient expectations affect their satisfaction with the center.
Patients expect that the urgent care provider will treat all issues in one visit. The public wants “one-stop convenience” and does not concern itself with level of service, throughput, and other operational issues of the urgent care provider. Referring a patient for a return visit may result in a dissatisfied patient who not only doesn’t return—but who also spreads negative word-of-mouth damaging the center long- term. From a brand-building and marketing perspective, if the provider has time, it’s generally best to address all patient issues the patient in one visit.
Billing and Reimbursement
From a billing perspective, large national payers tend to contract with urgent care using flat-fee contracts that pay the same amount per visit regardless of the level of service performed. With these contracts, treating multiple issues in one visit can result in greater potential revenue loss than in fee-for-service.
But even with fee-for-service contracts—if a visit bills as a “Level 4” (99214) and multiple issues are addressed—unless those additional issues entail an x-ray, procedures, or lab tests, the E&M level does not change; this means there’s no additional reimbursement for the additional time spent.
Requiring a patient to return for subsequent visits should result in higher total reimbursement to the center but, again, a patient who becomes dissatisfied with incurring multiple copays and multiple charges against his deductible may damage the center’s reputation through negative word-of-mouth.
The “no win” choices of the urgent care operator are thus to forego additional revenue from multiple visits or to spend additional funds on advertising to recruit a new patient to replace the disgruntled patient who refuses to return to the center because its “doctors wouldn’t help me.”
However, during times of high-volume or staff shortages, the urgent care center should rely on careful scripting by the nursing staff and the provider to ensure patient satisfaction, throughput of the clinic, and high-quality medical care. Scripting can be variable, but should include elements of sincerity, setting an expectation of what can be accomplished at this visit, and discussion of when other issues can be addressed.
For instance, if a patient reveals to the clinical staff that they have five separate issues to cover, the staff may let the patient know “We would like to ensure we give you our best quality care today. The provider will do everything possible to address all of your issues today. But, if you had to pick the top two that are most concerning, what would they be?” The clinical staff should then note the top two of the five complaints. The provider should make every attempt to assess the five complaints to make sure they are unrelated and address the top two complaints of most concern. “I see here that you have several complaints but your most important are A and B? Is that correct? Let’s discuss these issues and then we can discuss how we can best resolve the others at the end of the visit.”,
This is a form of shared decision-making and patients often respond positively when they are involved in the decisions regarding their health.
In the urgent care setting, it’s always a balance between the one-stop convenience patients demand and providing the best care in the allowable time possible. With careful consideration and diplomacy, you really can serve those two masters to the benefit of the patient and your operation.
