Wiki MD and APRN see patient same day -commercial ins. Help!

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kseverson

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Help! This is for a commercial insurance patient. We are a multi specialty group. Our physician and an APRN see an established patient on the same day. The APRN charges (under her name) by time 99214. The physician charges by medical decision making 99214. How would you bill this?
 
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The following is from CMS. Although this applies to Medicare, most, if not all, commercial payers will fall into line with this guidance.


30.6.5 - Physicians in Group Practice(Rev. 1, 10-01-03)

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. 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.


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Ryan Stroup, CPC
 
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rstroup said:
The following is from CMS. Although this applies to Medicare, most, if not all, commercial payers will fall into line with this guidance.


30.6.5 - Physicians in Group Practice(Rev. 1, 10-01-03)

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. 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.


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Ryan Stroup, CPC
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Thank you for your information. I understand that if this was a Medicare patient, both visits could be billed because Medicare uses the physician specialty the practitioner is enrolled under.
rstroup said:
The following is from CMS. Although this applies to Medicare, most, if not all, commercial payers will fall into line with this guidance.


30.6.5 - Physicians in Group Practice(Rev. 1, 10-01-03)

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. 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.


--
Ryan Stroup, CPC
Click to expand...
Thank you for your information! Yes, I do understand if this was for a Medicare patient that both the physician and the APRN could both bill for their visits on the same day (pending medically necessary) because Medicare uses the physician specialty the practitioner is in enrolled under. So two different specialties in this case...APRN and MD. My confusion is when this is not a Medicare patient. The CPT rule is to consider NPs and PAs as working in the exact same specialty as the practice in which they are assigned. So if the APRN is billing a 99214 by time under their name and the physician is billing by MDM under their name how would you bill for those services? Would you bill each visit separately and if one is denied, try to appeal or just bill one of the visits (the one with the highest level). Thanks!
 
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AmandaBriggs said:
Are they two different specialties? If so, you will likely need to appeal the nurse practitioner's claim showing that they practice under a different specialty than the physician.
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Yes, 2 different specialities...APRN and MD per Medicare. Medicare uses the physician specialty the practitioner is enrolled under to process their claims. However, that is not the case with most commercial insurance companies. My question is how to bill both charges for a commercial patient. Thank you!
 
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amyjph said:
Did they both see them for the same problem? Was the patient seen for two different problems/two different subspecialties?
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The patient was seen by the APRN for a chemotherapy overview that lasted 35 minutes. She's billing by time under her name. The physician saw the patient in follow-up to their cancer diagnosis going over their recent labs, recent radiology studies, and to refill a medication.
 
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