New Patient Visit for Same Practice Subspecialist

New Patient Visit for Same Practice Subspecialist

Question: A referring provider and subspecialist are in the same practice and bill under the same tax ID; however, the referring provider is an obstetrician/gynecologist,and the subspecialist is a gynecologist obstetrician. Can the gynecologist obstetrician bill a new patient visit?

Answer: Per the CPT® definition, a new patient is one who has not received any…

  1. professional services
  2. 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,
  3. within the past three years.

Let’s consider these requirements, one at a time.

In this context, professional servicesare face-to-face medical services. CPT® E/M Services Guidelines stress, “Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT® code(s).” The Centers for Medicare & Medicaid Services’ Medicare Claims Processing Manual, Chapter 12 (30.6.7), confirms, “An interpretation of a diagnostic test, reading an X-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

Within the past three years is straightforward: If the gynecologist obstetrician specialist in question hasn’t seen the patient face-to-face within the previous three years, we’ve already met two of the three requirements to report a new patient visit.

The remaining condition, that if the provider is in the same group practice they must be of a different specialty or subspecialty, is the potential sticking point. Different payers may designate specialist and subspecialists in different ways, so you’ll need to know your particular payer’s rules (typically, the specialty/subspecialty designation is determined by how the provider was credentialed).

Medicare classifies “Allopathic & Osteopathic Physicians/Obstetrics & Gynecology, Gynecologic Oncology” (207VX0201X) as a subspecialty distinct from “Allopathic & Osteopathic Physicians/Obstetrics & Gynecology” (207V00000X). So, if we’re reporting to Medicare, and if we assume the gynecologist obstetrician is appropriately designated, they will meet the requirement of “different subspecialty” (for Medicare patients, you can use the National Provider Identifier (NPI) registry to see which specialty the physician’s taxonomy is registered under).

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

7 Responses to “New Patient Visit for Same Practice Subspecialist”

  1. Christine Speroni says:

    The article states doc 1 is ob/gyn and doc 2 is gyn OBSTETRICIAN. However when you reference CMS specialties it states gyn ONCOLOGIST. Yes, a gyn ONCOLOGIST is a different specialty than ob/gyn. There is not a difference between ob/gyn and gyn/ob as your scenario is presented.

  2. Marvel J Hammer says:

    I don’t see the reference to Gynecologist/ Oncologist in the question. What is listed is Gynecologist/Obstetrician which would highly likely be considered the same speciality as Obstetrician/gynecologist – the referring physician.

  3. L says:

    Hi. Not sure I’m comprehending the article accurately. Are you stating that an “obstetrician gynecologist” and a “gynecologist obstetrician” are two different specialties? Could you please expound upon that further? One of the taxonomy codes listed at the end of the article mentions gyn onc, but I don’t see that specialty referenced elsewhere in the rest of the article. Was one of the providers in the scenario actually supposed to be referenced as a “gyn oncologist”? Thank you for any clarification you can provide.

  4. L says:

    Hi. Not sure I’m comprehending the article appropriately. Are you stating that an “obstetrician gynecologist” and a “gynecologist obstetrician” are two different specialties? I noticed one of the taxonomy codes mentioned above is for gyn onc, but that specialty isn’t mentioned elsewhere in the article. Was one of the providers in the scenario supposed to be a gyn oncologist perhaps? Thank you for any clarification you can provide.

  5. Christine Speroni says:

    This article is worded incorrectly, confusing the words obstetrician and oncologist, thereby giving incorrect information. Yes, a provider of a different subspecialty in the same group may bill a new patient visit. However, your question states the subspecialist is a gynecologist OBSTETRICIAN. Further, you define the taxonomy code of gynecologic ONCOLOGY. There is no taxonomy code for gynecologist obstetrician. Below are the taxonomy breakdowns falling under general ob/gyn 207V00000X.
    Critical Care Medicine – 207VC0200X
    Female Pelvic Medicine and Reconstructive Surgery – 207VF0040X
    Gynecologic Oncology – 207VX0201X
    Gynecology – 207VG0400X
    Hospice and Palliative Medicine – 207VH0002X
    Maternal & Fetal Medicine – 207VM0101X
    Obesity Medicine – 207VB0002X
    Obstetrics – 207VX0000X
    Reproductive Endocrinology – 207VE0102X

  6. Jim Leach says:

    I think you had a typo in your article “Question.” You stated “the referring provider is an obstetrician/gynecologist,and the subspecialist is a gynecologist obstetrician.” I think you meant to say the subspecialist is a gynecologist oncologist.

  7. pauline grant says:

    does this same rule apply for a FQHC facility?

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