Ophthalmology and Optometry Coding Alert

Question: We received a memo from our Part B Mac, NGS Medicare, about new rules for nurse practitioners and physician assistants, but we can’t make heads or tails of it. Do you have an explanation of how we are supposed to be reporting these services?

Codify Subscriber

Answer:  Effective Sept. 15, Part B MAC NGS Medicare is instituting new guidelines that will add an extra step when filing claims if your ophthalmology advance practice provider (APP) sees a patient the same day as another APP in your practice who works in a different specialty area. The rule will mostly affect APPs in multispecialty practices.

Background: NGS identified claims for E/M services that were submitted by nurse practitioners (specialty 50) and physician assistants (specialty 97) and the services were often performed more than once per day by advanced practice providers working in different subspecialty areas, despite being in the same practice. Traditionally, the first claim would be paid and the second claim would be denied, and then the practice would appeal it with information that supported care for a different clinical problem, resulting in payment upon appeal.

CMS permits one E/M service per beneficiary per date of service for each provider specialty, but because only one specialty designation exists for NPs (50) and one for PAs (97), two claims by an NP on the same date for the same patient at your office will prompt a denial, said NGS’ Cathy Delli-Carpini during the company’s Aug. 23 webinar, “NGS Editing Change for Nonphysician Practitioner Evaluation and Management Services.”

In an effort to fix the issue, NGS created a new process requiring you to indicate the specialty of the group in which the NP or PA is performing the service. The claim will still come in with a rendering provider of specialty 50 or specialty 97, “but what we’ve asked you to do now is go to that 2300 or 2400 NTD loop on the electronic claim or box 19 on the paper claim and insert the specialty of the group in which you are working that day,” Delli-Carpini said.

That way, if a second or third claim comes in for specialty 50 or 97, the claim examiner can look at the claim history, see which specialty NGS paid it to initially, and if indeed those two specialties are different, the claim examiner will move on and compare the diagnosis on the history claim and on the current claim. “Remember, both of those have to be different. So a situation in which a claim coming in from cardiology and one from internal medicine with a NP on both claims, if the diagnosis information is the same, that claim will not be payable. But if the two supervising specialty information sets are different and the diagnoses on the current claim and history claim are different, the claim may be considered for payment,” she added.

NGS stressed that you shouldn’t insert extra information into the field about your claim – simply add the supervising specialty. You’ll use the specialty code that CMS has assigned to your specialty. For ophthalmology, that’s code 18, so in the appropriate field, your biller will write “SPEC 18” to reflect that an NP or PA in the ophthalmology specialty performed the service.