The answer really depends on the payer. Are the providers in the same specialty or different specialties/subspecialties? Providers within the same group and with the same tax ID number may have different specialties/subspecialties; therefore, it doesn't necessarily matter if the tax ID is the same if a provider in the same group is a different subspecialty and thus is reporting a new patient code. If they are the same specialty and same group tax ID, you likely cannot bill the patient as a new patient within three years, but check with the payer.I am wondering what constitutes "same group" when determining a new vs est. patient code to use. Is it the billing NPI? Or is it the Tax ID? We have several practices under one Tax ID but they bill under different billing NPI's. I have payers denying for use of the new patient code but the patient was not seen in our group. I can only assume the payer is using the Tax ID?
Thanks Leesa and Thomas! They are of the same specialty so Tax ID is the key.The answer really depends on the payer. Are the providers in the same specialty or different specialties/subspecialties? Providers within the same group and with the same tax ID number may have different specialties/subspecialties; therefore, it doesn't necessarily matter if the tax ID is the same if a provider in the same group is a different subspecialty and thus is reporting a new patient code. If they are the same specialty and same group tax ID, you likely cannot bill the patient as a new patient within three years, but check with the payer.
You can submit the claim as a new patient encounter if the providers are of different subspecialties, but your payer may deny the claim based on the same tax ID (which may be what is happening in your case). If that is the case, consider appealing the denial.
Remember, too, that what your practice calls a subspecialty may not be recognized by the payer as a subspecialty. So be sure to check with your payer; and appeal any new patient claims that you feel warrant new patient codes, instead of established patient codes, due to subspecialty differentiation between providers.
Hope that helps!
Leesa A. Israel, BA, CPC, CUC, CEMC, CPPM, CMBS, AAPC MACRA Proficient
Head of Publishing, Editorial & Technology
AAPC
Unfortunately, I think you'll need to talk to a payer rep. I may be more of an issue that they are only accepting/paying on one provider per day with the codes you're using.Thanks Leesa and Thomas! They are of the same specialty so Tax ID is the key.
I do have another issue that Leesa touched on where I have an Internal Medicine provider that has a subspecialty of Geriatrics. She has been rounding at the hospital but our claims continue to bump up against the other Internal Medicine doc who is rounding as well and ours are getting denied. We have changed her taxonomy on our claims to reflect Geriatrics and we have updated her PECOS to reflect Geriatrics but to no avail for a few payers -- especially straight Medicare. Any insights on how to get our claims paid??