lori mitchell
Contributor
Hi. I've researched CMS resources including MedLearns, Chapter 12, concurrent care guidance in Chapter 15, as well as our MAC guidance, and have been unable to get clear definite direction on the questions below (I know, it's Medicare---what did I expect?).
1) For original Medicare, I understand the initial hospital care codes 99221-99223 should be applied for inpatient E/M services that would have been reported as consults prior to 2010 when Medicare stopped recognizing the consult CPT codes. However, what if the specialist hospital visit isn't for a consult but is a transfer of care (Admitting provider has asked specialist to see patient to manage a particular aspect of the patient's care, NOT to render an opinion)? Would the specialist still be able to report an initial from 99221-99223 for their first visit during that same hospital admission period?
2) I've been advised that Nurse Practitioners are not enrolled with original Medicare under a specific specialty of medicine and that only physicians are assigned specialties. I was told NPs are enrolled with Medicare literally with a "specialty" of "Nonphysician". Our Medicare MAC has also indicated they define a "physician group" as being all providers who bill under a given tax ID number. How are NPs regarded when it comes to published Medicare coding guidance regarding "same specialty" or "different specialty"? For example, an NP works for a Cardio practice who bills under a tax ID # that includes multiple practices of multiple different specialties, including other Cardio practices in other locations, Ortho practices, Internal Med practices, etc. From Medicare's perspective, is the NP considered to be the "same specialty" as ALL providers of ALL specialties who bill under that tax ID? Or is the NP only deemed "same specialty" to the Cardio providers? Or is the NP only "same specialty" to other NPs being billed under the same tax ID?
3) What if "Dr. Smith" admits a patient and sees them in the hospital for a few days and then asks a Nurse Practitioner (who bills under the same tax ID and under the same group NPI as "Dr. Smith") to see the patient on hospital day 4 and manage a specific aspect of the patient's care, based on the fact that the NP has taken some additional CME classes in a particular field (NP has no official certification or specialization, just classes)? Would the NP's first E/M service in that scenario be reportable to Medicare as an initial hospital care code 99221-99223, even though "Dr. Smith" had performed and billed an initial hospital care service previously on the day of admission? OR would the NP's first E/M service be limited to being a subsequent hospital visit 99231-99233?
4) As I said earlier, our MAC states they define a "physician group" as ALL providers who bill under a given tax ID number. However, I would have thought that the billing group NPI number would have been a factor in how Medicare defines a "physician group". Any input?
Again, all my questions are specific to original Medicare, not to Advantage Plans or other payers. Thank you so much for your help. When possible, please include authoritative resources that support your perspective.
1) For original Medicare, I understand the initial hospital care codes 99221-99223 should be applied for inpatient E/M services that would have been reported as consults prior to 2010 when Medicare stopped recognizing the consult CPT codes. However, what if the specialist hospital visit isn't for a consult but is a transfer of care (Admitting provider has asked specialist to see patient to manage a particular aspect of the patient's care, NOT to render an opinion)? Would the specialist still be able to report an initial from 99221-99223 for their first visit during that same hospital admission period?
2) I've been advised that Nurse Practitioners are not enrolled with original Medicare under a specific specialty of medicine and that only physicians are assigned specialties. I was told NPs are enrolled with Medicare literally with a "specialty" of "Nonphysician". Our Medicare MAC has also indicated they define a "physician group" as being all providers who bill under a given tax ID number. How are NPs regarded when it comes to published Medicare coding guidance regarding "same specialty" or "different specialty"? For example, an NP works for a Cardio practice who bills under a tax ID # that includes multiple practices of multiple different specialties, including other Cardio practices in other locations, Ortho practices, Internal Med practices, etc. From Medicare's perspective, is the NP considered to be the "same specialty" as ALL providers of ALL specialties who bill under that tax ID? Or is the NP only deemed "same specialty" to the Cardio providers? Or is the NP only "same specialty" to other NPs being billed under the same tax ID?
3) What if "Dr. Smith" admits a patient and sees them in the hospital for a few days and then asks a Nurse Practitioner (who bills under the same tax ID and under the same group NPI as "Dr. Smith") to see the patient on hospital day 4 and manage a specific aspect of the patient's care, based on the fact that the NP has taken some additional CME classes in a particular field (NP has no official certification or specialization, just classes)? Would the NP's first E/M service in that scenario be reportable to Medicare as an initial hospital care code 99221-99223, even though "Dr. Smith" had performed and billed an initial hospital care service previously on the day of admission? OR would the NP's first E/M service be limited to being a subsequent hospital visit 99231-99233?
4) As I said earlier, our MAC states they define a "physician group" as ALL providers who bill under a given tax ID number. However, I would have thought that the billing group NPI number would have been a factor in how Medicare defines a "physician group". Any input?
Again, all my questions are specific to original Medicare, not to Advantage Plans or other payers. Thank you so much for your help. When possible, please include authoritative resources that support your perspective.