Can be very confusing. It can depend on how the payer views subspecialty designation, if they follow CMS, if they have their own rules where it only goes by Tax ID or NPI, etc. I have worked in some large groups where to streamline, the NP/PA would bill established if the patient was seen in the group by anyone within the past 3 years. I have also seen where coders had to figure out if the patient had been seen by the same specialty/subspecialty and who the supervisor was, etc. It can get very convoluted depending on the group size and composition. Some payers don't care about the taxonomy and only look at Tax ID or group NPI. It can also depend on how providers were credentialed and if the coder doesn't actually know or check that, it can be incorrectly coded also.
I think, in your question, you are asking if the
same NP sees the
same patient under two different subspecialties, can they bill new under both? If that is the case, I probably wouldn't do two new E/Ms. The mid-level provider has already seen the patient face-to-face regardless of the subspecialty they are working in that day. If it was two different NPs, maybe, but that depends on all the stuff above. If you are in a large group there should be a policy about this. It can take a really long time to scour medical records and for a coder to try and figure out if it is new vs. established. Could money be left on the table? Maybe. However, billing new when it should not be can also cause rejections, denials, and extra work on the back end.
Examples:
Non-Physician Practitioner in Multi-specialty Group - JE Part B - Noridian
Q: Will UnitedHealthcare reimburse New Patient CPT codes for Nurse Practitioners/Physicians Assistants reporting under providers of different specialties but same TIN?
A: No. Nurse Practitioners (NPs) and Physicians Assistants (PAs) are credentials of the practitioner (such as MD, DO), they are not considered specialty designations. Therefore, if a current claim comes in for a new patient E/M provided by an NP and there is a claim in history provided by an NP, with the same TIN, the current claim will deny, allowing the provider to review their documentation and resubmit with the appropriate established E/M service.
CMS manual:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
This may be an older post, but has really good explanations:
There are other articles on CodingIntel about the difference between new and established patients, and the rules haven’t changed, but that doesn’t mean it is always clear. Medicare definition "Interpret the phrase “new patient” to mean a patient who has not received any professional services...
codingintel.com
Specifically, this part:
"Commercial insurers usually follow the CPT® rule and consider the NPP as being of the exact same specialty as the physician (s) with whom they practice. As mentioned, insurance policies sometimes have a different deductible and different benefit categories for primary care and specialty services. The company considers the PA who works in an orthopedic office as a specialty provider and the PA who works in a Pediatric practice as a primary care provider. This allows them to process claims depending on if the visit is done in a primary care or specialty practice.
However, since Medicare considers all PAs of the same specialty, and all NPs of the same specialty, they process claims differently. In a multi-specialty group, if a patient sees an NP in oncology, that patient will be considered established if seen by any other NP working in any specialty. This can be challenging in a multi-specialty group if new patients are seen by NPs and PAs."