Urology Coding Alert

Question: I code for a multi-specialty practice. A patient counts as new if that patient hasn't been to anybody in the practice of the same specialty within three years.So, an internist and a urologist working in the same practice could both count the same patient as new on their first encounter with the patient. But is that true even when the internist's and urologist's claims are filed using the same group provider number?

Alaska Subscriber

Answer: If the group has a group national provider identifier (NPI), the providers will (or should) still have individual NPI numbers. While the biller will put the  group NPI number on the claim, that won't affect the "new versus established" debate if the providers are from different specialties. When you apply for the NPIs, you have to designate the physician's subspecialties on the application. So although they're billing under the same federal tax ID number, each physician is differentiated by his specialty with his NPI number. Keep in mind that the NPI does not replace the federal tax ID number on your claims.

Note: The determining factor in whether or not two physicians are practicing within the same "group" is the federal tax ID number. If the practice bills for both providers using the same federal tax ID number,then the two providers are considered part of the same group practice for coding purposes.

Example: If you bill for a practice that has an office in one city and a satellite office 90 miles away in another city, but there is one federal tax ID number for the practice, it is a "group" practice. If a urologist in one office sees a patient and two years later an urologist in the other office sees the same patient, physician No. 2 will bill using established patient codes.

Here's the exception: When physicians of different specialties see the same patient within the same 36- month period, the usual "new versus established" rules do not apply. "If a subspecialist has a specialist distinction that is different from that of the physician who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient," the June 1999 CPT Assistant states.

Problem: If the subspecialist within the same group practice has a separate taxpayer identification number (TIN) for his subspecialty, different from that of the general group TIN, then the patient receiving professional services from the subspecialist may be considered a new patient. That is easy to see. But what about when they bill with the same TIN?

Solution: The fact that the physicians bill under the same group NPI and federal tax ID number does notmatter in this case.

Example: If a patient presents to the internist under TIN 0000000 and the internist refers the patient to the urologist who is billing under TIN 0000000, and the patient has never seen the urologist before, then the urologist can bill a new patient code or consultation if the visit meets the requirements for a consultation.