Wiki New office visits and nurse practitioners

[lmclaughlin]

I work for a large multi=speciality group practice and we have nurse practitioners employed in all specalties. I need some clarification on the billing guidelines for new office visits and nurse practitioners.

CMS manual, chapter 12 , section 30.6.7a states that if a patient is seen by an NP and coded as a new office that a physician ( different specialty) can also bill a new office even if it's within the 3 year guideline.

My question is concerning two NP visits within the three year guideline but done by nurse practitioners in different specialties. Exampe: patient see by NP in Neurology on 1/1/15 and billed as a new office visit and then seen by a NP in Gastro on 4/1/15 and billed as a new office visit. Medicare is denying these and will not pay upon appeal.

 

[thomas7331]

This is a problem we've been fighting with also. Local Medicare carriers use the specialty identified in the 855i enrollment form for purposes of determine whether two providers are or aren't the same specialty. Unfortunately, NPPs cannot designate a specialty on the 855i, so they all look the same to the Medicare claims systems. I know that some carriers (e.g. Novitas) will allow you to appeal if you can show that the two NPPs are trained in different specialties, but I'm beginning to believe it's kind of a losing battle to try to argue that our NPPs are of different specialties for the purposes of reversing new patient claim denials.

 

[teresabug]

look at their profile on the NPPES database. They were also assigned a "taxonomy" code when they were enrolled. I have used this data to win appeals for patients seen by a hand surgeon within an ortho group.

good luck!