Wiki New Patient exam qualifications under the new 2023 EM rule

[MSCALLIE79]

Hello all,

I am a multi- specialty ophthalmology practice, and have a questions regarding an article we received from North American Neuro-Ophthalmology Society, I am trying to prevent denials, but my physician now have a questions since we have 6 subspecialties but we all bill under 1 Group NPI.
Can we bill a new patient exam under the sub-specialty taxonomy and each sub-specialty receive a new patient exam within the same group NPI?

Dear Members of the North American Neuro-Ophthalmology Society,

We would like to inform you of the new changes to billing E&M visits effective January 1, 2023. The new wording states that established patient visits (E&M 99212-99215) refer to patients seen within a practice by a physician “in the exact same specialty and subspecialty”. This means that a patient seen by a non-neuro-ophthalmologist within the same practice (cornea, glaucoma, retina, etc.) but not by the neuro-ophthalmologist should be billed as a new visit (E&M 99202-99205).

 

[jkyles]

Hi there, the new/established patient guideline is not new. You'll need to check individual private payer policies to see if they recognize sub-specialties. Medicare does not recognize sub-specialty.

 

[csperoni]

Yes, this is payor specific about whether or not they recognize the subspecialty and is not a new guideline. Most carriers will go by taxonomy codes. It is also important to be credentialed under the appropriate specialty when enrolling. There are many physicians who may have the same official specialty or subspecialty, but choose to practice in only a specific aspect. That is not accepted as different subspecialty.
Just a note about Medicare. Medicare does consider some subspecialties, they just use a much shorter list than taxonomy codes. For example, gynecologic oncology is a subspecialty of ob/gyn, but Medicare does recognize it as different.

https://medicare.fcso.com/pe_resources/138372.asp

I work in gynonc and urogyn for a large healthcare organization and deal with this all the time. My personal advice is:
1) Develop a list of carriers where you know whether they definitely will or definitely won't recognize the different subspecialties.
2) When billing a carrier where it's unknown if they will allow the separate specialty, bill as new. If denied for not new, create a form appeal letter explaining the different specialties/training of the physicians. If appeal is upheld, rebill corrected claim as established.