Wiki Pulmonary provider and Sleep Medicine provider billing with same tax ID number

[ardellt]

I work at a Pulmonary and Sleep Medicine Clinic.

The patient was seen for their initial visit for sleep issues and our provider(Sleep Medicine is their specialty) ordered a sleep study (done November 2020).

The sleep provider also referred the patient to one of our pulmonary doctors for a ‘pulmonary related issue’ that was noted during the sleep visit.

The pulmonary provider who got this referral had the patient complete a PFT and had their initial visit on the same day in December 2020.

The patient has UMR for insurance, and they do not accept consult codes, so we have to change the consult code to a new patient (if they haven’t been seen within the last 3 years).

In this case, I had to make the pulmonary visit, an established visit because they were seen by the sleep medicine provider billing under the same tax ID as the pulmonary provider. But the pulmonary doctor is disagreeing with me on this because they are 2 different specialty visits, so both visits should both be charged as a New Patient visit.
The CPT book says "A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the last three years."

Are we doing this wrong?? Can we charge both visits as a new patient because they are 2 different specialties? Or because they’re in the same group practice, only 1 can be new?
Thank you

 

[thomas7331]

The doctor is correct - if the patient is new to the specialty, then they are a new patient even if they have been seen by a provider of a different specialty in that same group within three years. The only problem you may run into is that different payers will assign a specialty in different ways. For example, Medicare will require the provider to declare their specialty at the time of enrollment and will not consider a subspecialty. Some commercial payers, though, may use the primary taxonomy that is listed for the provider with their NPI number. So depending on how your providers are set up in the payer's claim system, a new patient code may be denied so it may be necessary in certain cases to either rebill as an established patient or appeal the denial with additional information about the provider's specialty.