Wiki Exception to the 3 yr rule

[PKOHUT]

The 3 year rule...I get that. However, I was thrown a curve ball and don't know how to respond to this reply. Can someone help me please?
If an established patient in our practice sees our hand specialist]for a hand problem and then sees another Ortho in our practice for a non-hand issue within the 3 years, then the patient is still new to the treating physician.
I was told this is an exception to the rule. I see it as a new problem -established patient. If the ins company looks at the TaxID, it is established as all providers in the practice are under the same Tax ID. Thank you for your help in advance.

 

[Pam Warren]

New problem, new patient. Look at the flow chart in CPT (page 5, AMA Professional edition). Subspecialties in the same practice account for a new patient.

 

[dzonks]

Exception to the 3 year rule

Pam,

At first I agreed with you but then I took a look at 2014 CPT. Look at the Decision Tree on page 5. It looks like you can bill out as a new patient because the providers have a different subspecialty. I learn something new every day!

Good luck.

 

[Pam Warren]

I thought that's what I said....new patient?

 

[KMCFADYEN]

Just make sure they are credentialed with their subspecialty with the insurance company you are filing to.

 

[Kmakar]

I think it depends on whether your hand subspecialist is also a general ortho. If they are going from the general ortho to a hand subspecialist you are fine. The subspecialty is different.

But, if they are both orthopaedic surgeons in their credentialling and one was also a hand subspecialist, and the original appts were with hand, then going to regular ortho, they would both be equals, no?

I say this because as a general ortho and hand subspecialist the hand guy can treat general ortho. So then it is ortho to ortho and not ortho to hand.

I chew this one over and over as we have hand and sports med subspecialties who are all credentialled as orthopaedic surgeons and their subspeciality. When it goes from a non-subspecialist to a subspecialist, it is easy peasy in my mind. But when the subspecialist send to a non-subspecialist and both are ortho surgeons... well, as you see, I have a different opinion (sometimes from day to day).

I would appreciate feed back on whether others are conflicted on this or can see a black and white view without my many shades of gray. Thanks.