# new patient or established?



## efuhrmann (Apr 13, 2009)

A patient was seen within the past three years by Family Practice provider in a multi-specialty clinic(all use the same tax ID#).  Same patient seen in Urgent Care and /or Internal Medicine.  Is this person a new or established patient, assuming all other conditions exist for a newbie?


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## LOVE2CODE (Apr 13, 2009)

efuhrmann said:


> A patient was seen within the past three years by Family Practice provider in a multi-specialty clinic(all use the same tax ID#).  Same patient seen in Urgent Care and /or Internal Medicine.  Is this person a new or established patient, assuming all other conditions exist for a newbie?



Established.....


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## kbarron (Apr 13, 2009)

We have a similar issue here. We are a Critical Access Hospital. Because the pt is seen by a different speciality they may be coded as new. If in an urgent /emergency room situation, the internal med provider saw the pt they would be new. If they follow up in the office then I would use the correct E&M code. Good Luck.


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## LOVE2CODE (Apr 13, 2009)

kbarron said:


> We have a similar issue here. We are a Critical Access Hospital. Because the pt is seen by a different speciality they may be coded as new. If in an urgent /emergency room situation, the internal med provider saw the pt they would be new. If they follow up in the office then I would use the correct E&M code. Good Luck.




What about the same TAX ID #?


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## kbarron (Apr 13, 2009)

We are the same tax id, different specialties.


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## LOVE2CODE (Apr 13, 2009)

kbarron said:


> We are the same tax id, different specialties.



OK....


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## kbarron (Apr 13, 2009)

It may be a good idea to track the claim and see what happens to it.


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## RebeccaWoodward* (Apr 13, 2009)

Elizabeth,

Your scenario seems very similar to our setting. We are a physician group practice. Within our group practice, we have an Urgent Care facility. Those physicians that work in our Urgent Care Center are Family Practice/Internal Med physicians. Once that patient/doctor relationship is established in our Urgent Care setting, they are established patients when they return to see our Internal Med or Family Practice physicians.  The patient likes the convenience of walking in without an appointment and decide to use our Urgent Care Center as their PCP. Many of our carriers stipulate in their contract that Family Practice/Internal Med is one in the same.  My opinion...this is an established patient based on your scenario.


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## Bsivera (Apr 14, 2009)

Are Urgent Care Centers required to pay additional fees just for operating during a 24 hour basis?  I have seen some Urgent Care Centers charge a couple hundred dollars under HCPCS code S9088--which is for an urgent care center (in addition to the service code byt the physician).  Why do you typically bill with this additional code and do you usually get paid for it?


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## RebeccaWoodward* (Apr 15, 2009)

Our Urgent Care Center does not function 24/7.  We are open 7 days a week but not past 7 p.m.  We charge a standard fee...


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## S Avara CPC (May 12, 2009)

*Urgent care codes*



Bsivera said:


> Are Urgent Care Centers required to pay additional fees just for operating during a 24 hour basis?  I have seen some Urgent Care Centers charge a couple hundred dollars under HCPCS code S9088--which is for an urgent care center (in addition to the service code byt the physician).  Why do you typically bill with this additional code and do you usually get paid for it?



Some insurance carriers pay additionally for the S9088.  It depends on how the contracts are set up with the carrier.  You don't have to be open 24/7 to charge this code.  You just have to be considered and contracted as an Urgent Care Facility.  Most of our clinics are open extended hours but close by 9 -11 pm and are open 7 days a week.  

Depending on the state and insurance the reimbursement can be between $8 - $80

There are additional fees associated with operating an Urgent Care Facility.  Appointments are not scheduled, there are extened hours and most are open 7 days a week.  Unscheduled appointments mean that patient flow in the urgent care center is quite unpredictable, so the urgent care center will sometimes be open for hours, serving no patients and generating no income. Meanwhile, the expenses of salaries, benefits, heating/cooling, etc. will continue to accrue. Staff in primary care physician offices generally work bankers hours. Staff in urgent care centers work weekends, holidays and evenings. Thus, hourly compensation for urgent care staff will reflect this differential, resulting in higher wage costs for the same staffing.


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## caroline75771 (Jun 5, 2009)

*Urgent Care and Pediatric*

Quick question ... does this hold true if patient went to our Urgent Care (new patient) and then 2 weeks later saw our Pediatric physician?  Is the patient considered an established pt?  Is Pediatric considered Family Practice/Internal Med ?

Thank you
Caroline


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## Karolina (Jun 5, 2009)

A patient is established once the provider or another member of the group/specialty has seen the patient. A patient is also established if the provider has seen the patient before while working for a different group - basically if the provider who sees the patient today has seen the patient before (face-to-face) today's visit will be established. It doesn't matter where the patient was seen before - urgent care, office, inpatient....
Only if more than 3 years have passed since the prior encounter this may be a new patient (again).


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## Karolina (Jun 5, 2009)

How are your involved providers credentialed? If one is internal med and the other is pedi they are different specialties...


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## caroline75771 (Jun 5, 2009)

Our urgent care doc's are credentialed as Family Practice and our Peds doc as Pediatric.  So I guess the patient would be established....  I thought Pediatrics would be the same as Internal Med/Family Practice.


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## pamtienter (Jun 8, 2009)

Caroline,

If the patient was seen by Family Med/Internal Med in Urgent Care then seen in Peds later, they would be new in Peds if they haven't been seen by that Pediatrician, or one in that group (same FEDID), within the last 3 years.


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## caroline75771 (Jun 9, 2009)

Thank you Pam!


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