Practice Management Alert

Answer: If the group has a group national provider identifier (NPI), the providers will (or should) still have individual NPI numbers. While the biller will put the group NPI number on the claim, that won't affect the "new versus established" debate if

the providers are from different specialties. When you apply for the NPIs, you have to designate the physician's subspecialties on the application. So although they-re billing under the same federal tax ID number, each physician is differentiated by

his specialty with his NPI number. Keep in mind that the NPI does not replace the federal tax ID number on your claims.

Note: The determining factor in whether or not two physicians are practicing within the same "group" is the federal tax ID number. If the practice bills for both providers using the same federal tax ID number, then the two providers are considered

part of the same group practice.

Example: If you bill for a practice that has an office in one city and a satellite office 90 miles away in another city, but there is one federal tax ID number for the practice, it is a "group" practice. If an internist in one office sees a patient and two

years later an internist in the other office sees the same patient, physician #2 will bill using established patient codes.

Here's the exception: When physicians of different specialties see the same patient within the same 36-month period, the usual "new versus established" rules do not apply. "If a subspecialist has a specialist distinction that is different from that

of the physician who provided a previous service to the patient, you may consider the patient receiving professional services from that subspecialist to be a new patient," the June 1999 CPT Assistant states.

Problem: If the subspecialist within the same group practice has a separate taxpayer identification number (TIN) for his subspecialty, different from that of the general group TIN, then the patient receiving professional services from the

subspecialist may be considered a new patient. That is easy to see. But what about when they bill with the same TIN?

Solution: The fact that the physicians bill under the same group NPI and federal tax ID number does not matter.

Example: A patient presents to the internist under TIN 0000000 and then nine months later the patient presents with a new problem to a cardiologist who is also billing under TIN 0000000. The patient has never seen the cardiologist before, so the

cardiologist can bill a new patient code.

Potential snags: A problem could arise if one of the physicians in your practice has been credentialed with Medicare as a different specialty than he is actually practicing under. For example, if the physician credentials with Medicare as an

internal medicine physician when he is in actuality an endocrinologist, Medicare will deny services that this physician bills as "new patient" if the patient has seen an internist within the same practice during the three-year period. In this situation,

you should ask Medicare to change the physician's specialty designation.

Another potential snag you may run into is if you bill for a sub-subspecialty that Medicare doesn't yet designate. For example, otology is a sub-subspecialty of otolaryngology. An otologist is considered part of the otolaryngology specialty based

on the NPI application and Medicare's designations, and it is almost impossible for an otologist to successfully bill for a new patient within three years of the patient seeing a general otolaryngologist in the same practice. Other sub-subspecialties

that might run into this issue include neuro-ophthalmology and neurology-otology, among others.