Wiki Billing New Patient vs Establish Patient With a New Speciality Designation

[Trinna.Success]

If a physician or another physician in the General Cardiology specialty and group saw a patient and then the physician or another physician Specialty changed to Heart Failure or Electrophysiology and they saw that same patient (less than 3 years), would the patient be billed as a new patient or established? Please answer with the definition of New and Established Patient and possibly the Decision Tree for New vs Established in mind. I'm not asking what would be ethical, I'm asking what is allowed by guidelines and/or regulation. Thanks.

 

[CodingKing]

It will likely be based off what specialty is on file with the payer. For instance if they both have the same taxonomy code they are the same specialty and subspecialty.

 

[thomas7331]

Yes, different payers define specialty and subspecialty differently. Some payers use the taxonomy code on file with the NPI number, others (including Medicare) use the specialty that is declared on the enrollment form, and some even create their own specialty categories. I think the key is that if you're billing as a new patient and the claims are denied or audited, you be prepared to submit some kind of documentation to show that your providers are trained or licensed in different specialties or sub-specialties.

 

[Trinna.Success]

It will likely be based off what specialty is on file with the payer. For instance if they both have the same taxonomy code they are the same specialty and subspecialty.

Thanks CodingKing. I realize too that CMS definition of New Patient is different from the CPT manual, they did not include the wording "exact same specialty", so I think this means the patient would be billed as established.


30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215)
(Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)
A. Definition of New Patient for Selection of E/M Visit Code
Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

 

[Trinna.Success]

Yes, different payers define specialty and subspecialty differently. Some payers use the taxonomy code on file with the NPI number, others (including Medicare) use the specialty that is declared on the enrollment form, and some even create their own specialty categories. I think the key is that if you're billing as a new patient and the claims are denied or audited, you be prepared to submit some kind of documentation to show that your providers are trained or licensed in different specialties or sub-specialties.

Thanks Thomas7331 - This makes sense, thanks for the insight! I do believe with CMS definition of new patient, we would have to bill the patient as Established.