Wiki Sub Specialties

[NM36]

Hi,
What cardiac subspecialties are considered separate specialties for billing purposes?
For example, patient seen by Interventional Cardiology and Cardiac Surgery (within same group practice/TIN), are separately billable, correct?
Are Adult Cardiology, Pediatric Cardiology, EP, and Advanced HF also separate subspecialties?
What about when midlevel providers (PAs and NPs) credentialled to do their own billing see patients in different subspecialties? Are they also separately billable? I see a lot of denials (as duplicates or established vs new) when midlevels are involved regardless of the specialty. Is this preventable? Appealable?

Thanks!

 

[NM36]

To answer my own question, I found CMS recognizes these separate specialties;
Cardiology
Cardiac Electrophysiology
Cardiac Surgery
Interventional Cardiology
Advanced Heart Failure and Transplant Cardiology

For midlevel providers, they do not have separate specialties assigned beyond their credentials such as NP or PA. However, since CMS considers them to be under the same specialty as "the physician specialty area in which service is provided," NGS Medicare suggests including their associated specialty on the 2300/2400 Loop in the NTE Segment on electronic claims.

Has anyone had any experience with this, and does it work to avoid or reduce denials for 2 separate encounters same dos between specialties?
Thanks.

 

[csperoni]

For recognized subspecialties, see https://www.ngsmedicare.com/web/ngs...eId=1573546&lob=96664&state=97133&rgion=93623.

For ACPs, we include the information of the supervising physician. So if patient sees NP in cardiology and NP in endocrinology the same day, both claims will be paid on initial submission without a need for appeals or re-opening.
NGS has a very good references explaining this (links embedded).
Please explain the new vs. established patient rules for NPPs (PAs and NPPs) working in different specialty areas. Answer: NPs are designated by CMS as specialty 50, and PAs are designated as specialty 97. CMS, in consensus with AMA CPT, considers NPPs who are working with physicians as working in the exact same specialty or subspecialty as the physician. For example: a new patient visit by an NP working within internal medicine may be payable to the same group in which an NP working within cardiology has already been paid within three years. Additional information is required on NPP claims to allow these multiple first visits. When the additional information is not included on both claims, the second claim will deny and may be submitted as an appeal, with documentation of the first paid service along with the current service. Please refer to Nonphysician Practitioners – Reducing Costly Appeals; Increase Provider Revenue for NGS’ guidelines for NPP billing.

How do NP and PA providers include physician specialty information on their claims? Answer: This information is to be included in the 2300 NTE Loop Segment on electronic claims or in Box 19 on paper claims. The claims are to be submitted with either NP (Specialty 50) or PA (Specialty 97) as the rendering provider as usual, with this additional information entered separately, describing the specialty of the physician practice in which the care was rendered.

How will NGS be processing these NP and PA E/M claims? Answer: The first E/M claim from an NP or PA on a DOS will process as usual, however, subsequent NP and PA claims on that DOS will be suspended for review of the physician specialty group information and also a comparison of the diagnoses on the paid claim vs. any subsequent claim. When both the physician specialty information and the diagnosis code on the two claims are different, the second claim may be payable.

In a group practice, can more than one new patient visit be paid to a physician, NP, or PA provider within a three-year period? Does this apply to situations when both a physician member and an NP or PA member submit a claim for a new patient visit within a three-year period? Answer: A patient is considered new to a same-specialty group only once within a three-year period. In a multi-specialty group, a second new visit may be payable when the specialties on the history and pending claims are different. This rule also applies to new visits by NPs and PAs in a group, but only when there is information (as described above) on both claims that allows NGS to apply this ‘different specialty’ rule to the pending claim. When this information is missing on either the paid or pending claim, the second service will be denied and the denial may be appealed.

 

[NM36]

For recognized subspecialties, see https://www.ngsmedicare.com/web/ngs...eId=1573546&lob=96664&state=97133&rgion=93623.

For ACPs, we include the information of the supervising physician. So if patient sees NP in cardiology and NP in endocrinology the same day, both claims will be paid on initial submission without a need for appeals or re-opening.
NGS has a very good references explaining this (links embedded).
Please explain the new vs. established patient rules for NPPs (PAs and NPPs) working in different specialty areas. Answer: NPs are designated by CMS as specialty 50, and PAs are designated as specialty 97. CMS, in consensus with AMA CPT, considers NPPs who are working with physicians as working in the exact same specialty or subspecialty as the physician. For example: a new patient visit by an NP working within internal medicine may be payable to the same group in which an NP working within cardiology has already been paid within three years. Additional information is required on NPP claims to allow these multiple first visits. When the additional information is not included on both claims, the second claim will deny and may be submitted as an appeal, with documentation of the first paid service along with the current service. Please refer to Nonphysician Practitioners – Reducing Costly Appeals; Increase Provider Revenue for NGS’ guidelines for NPP billing.

How do NP and PA providers include physician specialty information on their claims? Answer: This information is to be included in the 2300 NTE Loop Segment on electronic claims or in Box 19 on paper claims. The claims are to be submitted with either NP (Specialty 50) or PA (Specialty 97) as the rendering provider as usual, with this additional information entered separately, describing the specialty of the physician practice in which the care was rendered.

How will NGS be processing these NP and PA E/M claims? Answer: The first E/M claim from an NP or PA on a DOS will process as usual, however, subsequent NP and PA claims on that DOS will be suspended for review of the physician specialty group information and also a comparison of the diagnoses on the paid claim vs. any subsequent claim. When both the physician specialty information and the diagnosis code on the two claims are different, the second claim may be payable.

In a group practice, can more than one new patient visit be paid to a physician, NP, or PA provider within a three-year period? Does this apply to situations when both a physician member and an NP or PA member submit a claim for a new patient visit within a three-year period? Answer: A patient is considered new to a same-specialty group only once within a three-year period. In a multi-specialty group, a second new visit may be payable when the specialties on the history and pending claims are different. This rule also applies to new visits by NPs and PAs in a group, but only when there is information (as described above) on both claims that allows NGS to apply this ‘different specialty’ rule to the pending claim. When this information is missing on either the paid or pending claim, the second service will be denied and the denial may be appealed.

Thank you! Very helpful information.