Medicare Compliance & Reimbursement

Stand your ground when your carrier shoots you down on new patient visits.

Watch out: It's time to fight for new-patient visits when your patient sees another physician in your group, from a different specialty.

The rules: CPT says a new patient hasn't received any services "from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." The Medicare Claims Processing Manual says physicians "in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group." (Chapter 12, section 30.6.5).

So if you work in a multi-specialty practice and your patient sees a physician from a new specialty, you can bill it as a new patient visit.

Problem: Some Medicare carriers have started rejecting new patient visits for transfers within a group, says Lisa Linville, a coder with a Missouri multi-specialty group. "Their interpretation is if a group shares the same tax ID number they also share the same records," and thus shouldn't bill separately, she says. Other payors have followed Medicare's lead.

Solution: You should appeal these sorts of denials, urges Laura Talbert with Shore Billing & Management in Allen, MD. Cite the language in Medicare's own manual, and point out that two different specialties are involved, and it could be a fairly simple appeal, she advises.

"You need to argue with the carrier," agrees Philip Eskew, medical director for women and infant services with St. Vincent Hospital in Indianapolis, IN. "They're hoping you don't push it," but you should send in a photocopy of the CPT rules and claims processing manual if necessary. Best practice: Keep an eye on your explanation of benefits (EOBs) to see if your claims are being denied or downcoded, he urges.

When a physician from a new specialty sees a patient for the first time, he or she still has to create a new database with a specialty-specific history and physical exam, Eskew notes. If the visit isn't a consult, it's definitely a new-patient visit, he adds.

Be careful: Some specialties may not count as separate in Medicare's eyes. For example, an electrophysiologist and a cardiologist are considered cardiologists under Medicare, says Maxine Lewis with Medical Coding Reimbursement Management in Cincinnati, OH.

Try this: If the carrier is denying new-patient visits for different specialties, try plugging in the doctor's separate Provider Identifier Number (PIN) instead of the group practice's ID, Lewis advises.