Wiki E/M new vs est

[kmtc613]

Hello,
In our ortho practice, we also have a sports medicine provider, all under the same Tax ID but different specialties.
If our ortho dr refers to the sports med dr, would it be a new or est visit for the sports med dr?
And, would the ortho dr put in a referral to the sports med dr, or is documentation in the note enough?
Thank you in advance.

 

[csperoni]

It depends how the providers are credentialed with insurance carriers with regard to their specialty.
In my experience, most payors credential by taxonomy codes. So if your providers are different taxonomies, the insurance will consider them different specialty/subspecialty and will pay as new. Some carriers (especially Medicare) go by a more limited list. If that more limited list considers them the same specialty, that payor will not pay as new.
Regarding a "referral" - it depends what you mean by referral. If this is simply an internal policy or order in your EHR system, it's up to your practice. If you mean an insurance approval, then yes.

 

[amyjph]

Agree with Christine. You have to know the taxonomy of the provider. Not all carriers even follow this, they may only look at the group EIN or the group NPI, then specialty and subspecialty won't matter. Some providers may even think they have a different one, but when you look it up they have the general orthopedic surgery one.
There is one catch all for ortho surgery and then 7 different subspecialties. There are also 2 separate ones for pain medicine if you have physiatrists in your group.

https://taxonomy.nucc.org/

Code	207X00000X
Name	Orthopaedic Surgery

Code	207XX0005X
Name	Sports Medicine

Generally providers within the same group don't make formal "referrals" to other members in their group. As Christine suggested, this is an internal policy.

 

[kmtc613]

Thank you both for your input!!