Wiki APRN and MD see patient 2 different days, new patient to both?

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kseverson

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We are an oncology practice. Our genetic counselor who is an APRN saw a patient for genetic counseling. She recommended genetic testing to the patient. She billed 99205. The patient tested positive for the BRCA2 gene mutation. The patient then saw our MD a week later. Can the physician also bill as a new patient?
 
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kseverson said:
We are an oncology practice. Our genetic counselor who is an APRN saw a patient for genetic counseling. She recommended genetic testing to the patient. She billed 99205. The patient tested positive for the BRCA2 gene mutation. The patient then saw our MD a week later. Can the physician also bill as a new patient?
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No. A new patient is one who has not received any professional services from the same group practice within the last 3 years.

Mid-level or nonphysician providers who work in your practice are considered the same specialty/subspecialty as your physician.

Whether or not it was appropriate for your APRN to bill 99205 for a genetic counseling visit is a different story, but I'm not looking at the documentation so I can't really say.
 
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kseverson said:
We are an oncology practice. Our genetic counselor who is an APRN saw a patient for genetic counseling. She recommended genetic testing to the patient. She billed 99205. The patient tested positive for the BRCA2 gene mutation. The patient then saw our MD a week later. Can the physician also bill as a new patient?
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The physician would bill it as an established patient. The midlevel is considered the same specialty as their physician.
 
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The reason I'm confused is because I watched a Medicare webinar a while ago and there was a similar question asked. This was the question:

"We have NPs and PAs throughout our clinic, in urgent care, family medicine, dermatology. If a patient sees NP in urgent care or acute care and then sees our doctor in internal medicine, would that be a new patient to the doctor?"

Ellen: For initial services, Medicare uses the physician specialty the practitioner is enrolled under. A nurse practitioner enrolls as a nurse practitioner. They're not the same specialty as any doctor; therefore, yes, that doctor has an initial visit. Medicare does not use taxonomy codes. These codes allow the nurse practitioners to identify practice specialties.
 
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I also always thought the midlevel was considered the same specialty as their physician. But after watching the Medicare webinar, doesn't it sound like from the question asked in the Medicare webinar that the physician could bill as a new patient? Sorry, just trying to get clarification.
 
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I believe it actually depends on HOW the ACP practices. In some states, NPs can own and have their own practice. In those situations, they enroll in Medicare on their own as an independent NP. However (at least around me), NPs are always working in a practice (or hospital system) in collaboration with a physician. NPs working for a practice are considered to be working in the same Medicare 2 digit specialty code as the physician. All their Medicare claims go with a supervising physician. This allows a new ortho patient seen by NP to be payable as new even if the patient saw an NP working for a GI practice within the same health system/TID. I know one of the MACs has some guidance about this. I'll look for it and add.
 
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Found the references for 2 MACs
Noridian https://med.noridianmedicare.com/we...ysician-practitioner-in-multi-specialty-group
"CMS editing only permits one new visit per provider specialty type within a group over a three-year period. Since NPs and PAs are two different provider designations, new visits by each within a three-year period may be payable. If the subspecialty information is missing on the original claim causing a denial, it may result in a provider submitting an appeal. However, Noridian's goal is to reduce the number of submitted appeals when the specialty and reason for the visit are different between the two E/M services. By placing the subspecialty in box 19 initially, it reduces the probability of a denial.
Example: if the patient was seen in a multi-specialty practice as a new patient by a specialty 50 working within family practice (specialty 11) and then seen within three years by a specialty 50 working within cardiology (specialty 06), the second new visit would be denied without the subspecialty information included in the comment field. If the documentation submitted with an appeal supported a medically necessary service addressing a distinctly separate problem, the second service may be payable on appeal. It is permissible to bill these services as subsequent visits, since they are considered as subsequent care by a same-specialty provider in the group. If the provider submitted both claims with the subspecialty information included in box 19, the claim would not have initially denied."

My MAC also allows new patient NPP based on the specialty of the supervising physician but specifies this ONLY applies to NGS and to consult the appropriate MAC if not NGS. Honestly, I thought this was CMS guidance and not MAC specific, but it might be.
https://www.ngsmedicare.com/documen...7-6c90-5794-9f2b-eb5e7f5c4abd?t=1668509782720

So, if you submitted the 99205 by the APRN correctly, who was the supervising provider and what is their Medicare 2 digit specialty code?
If this is not a Medicare patient, most commercial plans use taxonomy codes instead of CMS specialty codes to determine new/established.
If the MD is the same specialty as the supervising provider on 99205, this is established.
 
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csperoni said:
I believe it actually depends on HOW the ACP practices. In some states, NPs can own and have their own practice. In those situations, they enroll in Medicare on their own as an independent NP. However (at least around me), NPs are always working in a practice (or hospital system) in collaboration with a physician. NPs working for a practice are considered to be working in the same Medicare 2 digit specialty code as the physician. All their Medicare claims go with a supervising physician. This allows a new ortho patient seen by NP to be payable as new even if the patient saw an NP working for a GI practice within the same health system/TID. I know one of the MACs has some guidance about this. I'll look for it and add.
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I so appreciate your help. Our NPs work for our oncology group. Patient came in for a genetic counseling visit and saw our APRN. The same patient saw our physician a few weeks later because their genetic test came back positive. I just think it seems strange that the APRN would bill an established patient visit E/M when the patient is actually new to the practice. I would then think the physician should be able to bill a new patient code as well. What threw me off is when Medicare said: "For initial services, Medicare uses the physician specialty the practitioner is enrolled under. A nurse practitioner enrolls as a nurse practitioner. They're not the same specialty as any doctor; therefore, yes, that doctor has an initial visit."
I'm so confused...lol
 
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kseverson said:
I so appreciate your help. Our NPs work for our oncology group. Patient came in for a genetic counseling visit and saw our APRN. The same patient saw our physician a few weeks later because their genetic test came back positive. I just think it seems strange that the APRN would bill an established patient visit E/M when the patient is actually new to the practice. I would then think the physician should be able to bill a new patient code as well. What threw me off is when Medicare said: "For initial services, Medicare uses the physician specialty the practitioner is enrolled under. A nurse practitioner enrolls as a nurse practitioner. They're not the same specialty as any doctor; therefore, yes, that doctor has an initial visit."
I'm so confused...lol
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And there wouldn't be a supervising provider when our APRN originally saw the patient for the genetic counseling. This would be the patient's first time into the clinic and seen by the APRN. No physician involvement. The patient then saw our physician a couple weeks later.
 
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kseverson said:
We are an oncology practice. Our genetic counselor who is an APRN saw a patient for genetic counseling. She recommended genetic testing to the patient. She billed 99205. The patient tested positive for the BRCA2 gene mutation. The patient then saw our MD a week later. Can the physician also bill as a new patient?
Click to expand...
It depends how the office is set-up. Are all providers under a corporate tad ID. Also what is the patient's insurance?
 
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