Wiki New vs established pt involving NPP

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Rita Bartholomew

Rita Bartholomew

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Under Medicare's list of specialty codes, nurse practitioners have their own specialty code designation (50), under which are listed different specialization classications (adult medicine, geriatrics, pediatrics, etc.). A member of administration believes that if a "family practice" NPP sees a new patient, then the patient is seen by a "family practice" physician (both in our group of providers) within 3 years, then the physician can use the "new patient" codes.

It seems to me that they're confusing the specialty codes with the specialty itself, and that the 2nd visit with the physician should be "established". Can someone clarify this for me? Thanks.
 
That's the problem R.C., Medicare does not distinguish between physician and NPP in their definition of new vs. established patient. Per Medicare Claims Processing Manual 100-04, Chapter 12, section 30.6.7 (A): Interpret the phrase ?new patient? to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the PHYSICIAN (emphasis added by me) or physician group practice (same physician specialty) within the previous 3 years. The problem comes in when NPPs work in a multi-specialty group. I think it would be safe to say that if the NPP (e.g., Physician Assistant) is being supervised by a physician of a particular specialty, and that supervising physician or the NPP has seen the patient, then subsequent encounters by either the physician or the NPP would be established. If a ARNP is collaborating with a physician of a particular specialty, and that physician or the ARNP has seen the patient, then subsequent encounters by either the physician or the ARNP would be considered established.
But that is strictly my personal opinion. There is nothing in writing to support this.
I have submitted this question to CMS and have not heard back yet.
- Maryann
 
If a new patient is seen by a NPP, the 1st visit is billed as a new patient.
If the patient follows up & is seen by a provider NPP or physician in the
Same group, same specialty...this is billed as an established patient visit.
Hope this helps.
Arlene
 
Yes, the 2nd visit would be established. It is driven by the TAX ID #; if they are billing under the same TAX ID# then the subsequent visits within the 3 years are billed as established patients.
 
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