Wiki Nurse Practitioner in a specialty office

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salindarose

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Melvin, MI
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I have a claim for an NP at a neurology office submitted with a new patient E/M code. It is bumping up against another claim for an NP at a primary care office and denying stating it should be an established patient E/M. Both offices bill under the same tax ID but one is a neurology office and one is primary care. Do NP's not have a specialty attached to them like physicians do? Is this a legitimate denial?

Thanks!
 
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salindarose said:
I have a claim for an NP at a neurology office submitted with a new patient E/M code. It is bumping up against another claim for an NP at a primary care office and denying stating it should be an established patient E/M. Both offices bill under the same tax ID but one is a neurology office and one is primary care. Do NP's not have a specialty attached to them like physicians do? Is this a legitimate denial?

Thanks!
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We have to bill ours as established if a patient has seen another NP within the last 3 years with the same tax ID. We also have PAs and it's the same if the patient has seen another PA with the same tax ID.
 
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mk2001 said:
We have to bill ours as established if a patient has seen another NP within the last 3 years with the same tax ID. We also have PAs and it's the same if the patient has seen another PA with the same tax ID.
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Interesting, so there is no recognition of specialty when NP's and PA's are involved?
 
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salindarose said:
Interesting, so there is no recognition of specialty when NP's and PA's are involved?
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We are the cardiovascular & thoracic group for our hospital and bill our E/M's the same as Medicare allows even if it is a commercial insurance but here is what I have found from CodingIntel if it helps.

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.
 
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How does this apply in a hospital setting where two NP's of different physician specialities sees a patient on the same day. Medicare is only paying for one NP.
 
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Each claim should indicate who the supervising physician of the NP was for the service. If both claims properly indicated this, it should not have denied (at least not by my MAC). If both claims did not contain the necessary information for the MAC to know this information, you must appeal. The same situation occurs regarding when an NPP sees new patients.
 
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