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…
- 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 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).