Wiki New vs Est for practice w/separate tax ID's

[the2sims]

I have looked through previous threads, but still need help with New vs Established rules for my practice:
I have 3 orthopods, they each bill with their own tax ID. They share office space, EMR, staff and cover each other's patients as needed. They also call-share for emergencies at the local hospital.

Situation:
Pt is referred from ED for follow-up for a foot fracture and sees Dr.F. Dr.F wants the patient to see Dr.N (foot specialist), as Dr. F generally does total joints. Pt sees both docs on the same day in the same clinic. They both want to bill a New Patient visit.... can we do that?

Thanks!!!!!

 

[smonahan]

This is only my opinion, but I believe that would be very, very risky practice to bill new patient visits.

As an example, we have a provider who came to us from another clinic. He no longer works for that practice and has brought patients with him under a new tax ID. If that patient sees any of our providers (never seeing any provider except that same new provider we have) we always bill an established code. Technically, they have been previously seen by a provider in our group, even if it wasn't under our billing tax ID.

I would be curious even though they bill under their own tax IDs, if they work under the same clinic name of the same group, I would be very, very hesitant to bill new visit codes each visit.

 

[the2sims]

That is my thought too. But the Doc and the Office Manager insist it is OK because of the separate billing tax IDs. Thanks for weighing in - I would love to hear other opinions too

 

[thomas7331]

Medicare's definition of a 'group practice' can be found in Chapter 5, section 90.4 of the Medicare General Information Manual:

"A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association:
•In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, facilities, equipment, and personnel;
•For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group;
•In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group; and
•Which meets such other standards as the Secretary may impose by regulation to implement ?1877(h)(4) of the Social Security Act. The group practice definition also applies to health care practitioners.

Based on this, it does sound like maybe your providers could qualify as being separate 'groups' and you could bill new patients. But my recommendation is that since this involves some legal interpretation, you ask that your practice manager and owners review and make a written policy decision for the practice, that way, in the event that any payers audit or question it, you have something to refer to and are protected.

Another thing to consider, though, is whether the benefits will outweigh the risks. After all, coding for an established visit will often result in a higher level than for a new patient visit so it may not be a big benefit to code these as new patients. For example, if the provider is seeing a patient with a new problem, the same documentation could end up being coded as 99203 or 99214 which are roughly the same reimbursement, so it may not be that worthwhile financial to do this and take the chance that a payer might scrutinize your new patient visits at some point in the future.

Hope this helps some!