Optometry Coding & Billing Alert

Stand your ground when a carrier shoots you down

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.

Use CMS Manual to Back Up Claims

Problem: Some Medicare carriers have started rejecting new patient visits for transfers within a group, says Lisa Linville, CPC, 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 payers have followed Medicare's lead.

Solution: You should appeal these sorts of denials, says 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 says.

-You need to argue with the carrier,- agrees Philip Eskew, medical director with St. Vincent Hospital in Indianapolis. -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 explanations of benefits (EOBs) to see if your claims are being denied or downcoded, he says.

When a physician from a new specialty sees a patient for the first time, he still has to create a new database with a specialty-specific history and physical exam, Eskew says. 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, a retinologist is considered an ophthalmologist under Medicare, while optometry is a separate specialty.

-Ophthalmology is specialty code 18, which includes retinology, and optometry is specialty code 41,- says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

-However, a retinologist is considered a sub-specialist of general ophthalmology and, as such, may support reporting a consultation code when appropriately requested from a general ophthalmologist within the same group. But, it may be more difficult to justify billing a new patient visit for services rendered by both the general ophthalmologist and the retinal specialist within the same group. Be sure your documentation will support medical necessity.-

Try this: If the carrier is denying new patient visits for different specialties, try plugging in the doctor's separate provider identification number (PIN) instead of the group practice's ID.