New Patient E/M Denials: Mystery Solved

New Patient E/M Denials: Mystery Solved

New patient evaluation and management (E/M) claims are being denied when the patient was previously seen by a specialty physician assistant or specialty nurse practitioner on staff. This is happening when another provider of a different specialty in the same multi-specialty group sees the patient for the first time and bills a new patient E/M service.

Why Are New Patient E/M Claims Being Denied?

Medicare has only one taxonomy for physician assistants (PAs) and nurse practitioners (NPs), without any specialty designation. This means their services are not delineated or assigned to any particular specialty, even though they may be practicing a particular specialty. As a result, the patient is considered established to all the providers in the group when seen within the past three years, and all but initial new patient E/M visits performed at the multi-specialty group are automatically denied by the Medicare Part B carrier.

You Have the Right to Appeal

The new patient E/M denial does not have to stand. An appeal to the carrier, showing that the non-physician practitioner’s (NPP’s) specialty is different than the provider who is billing a new patient E/M, should get the claim paid correctly. Some Medicare Part B carriers, such as Novitas, allow you to use a re-opening to reprocess these claims. A spreadsheet with the following information will assist the carrier in reprocessing the claim accordingly:

  • Provider first and last name
  • NPI
  • Provider specialty and sub-specialty (if applicable)
  • Specialty code (optional)

Only Medicare approved specialties apply. A complete listing of the physician and non-physician specialties is available in the Internet Only Manual (IOM) Pub 100-04, Chapter 26 Completing and Processing Form CMS 1500 Data Set, Section 10.8.
Keep the spreadsheet on file to simplify all new patient E/M denial re-opening appeals.

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Barbara Cobuzzi

About Has 99 Posts

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is an independent consultant, CRN Healthcare Solution, Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

No Responses to “New Patient E/M Denials: Mystery Solved”

  1. Sonya Nugent, CPPM says:

    Thank you for this valuable information!