Wiki From a Compliance standpoint New vs Establish Pt When Provider becomes New Speciality

[Trinna.Success]

If a physician or another physician in the General Cardiology specialty and group saw a patient and then the physician or another physician Specialty changed to Heart Failure or Electrophysiology and they saw that same patient (less than 3 years), would the patient be billed as a new patient or established? Please answer with the definition of New and Established Patient and possibly the Decision Tree for New vs Established in mind. I'm not asking what would be ethical, I'm asking what is allowed by guidelines and/or regulation. Thanks.

 

[thomas7331]

I responded to your question under the billing forum - to recap, Medicare will consider only the specialty under which the provider was enrolled, and other payers may have different ways to define your providers' specialties but most will reconsider individual claims if you submit documentation to support how you made the determination.

From a compliance perspective, I'd recommend you research whatever payer guidelines you have available and come up with an internal process as to how you will define your provider's specialty within your practice, get sign-off from your management, and put this in writing as an internal policy & procedure. Doing this can go a long way to help protect you in the event there was ever a concern raised about compliance.

 

[Pam Warren]

If they saw the same patient within three years, it doesn't matter if the provider himself changed specialties or subspecialties. They would be established patients.

If the doctor saw the patient within three years, (regardless of where seen--old practice, new practice, new specialty, new problem) it's an established patient.

The specialty/subspecialty comes into play in this way:

We have cardiologists and vascular surgeons in the same practice. The patient is established with a cardiologist, and develops varicose veins. The cardiologist sends the patient to his practice colleague, the vascular surgeon, who the patient has never seen before. The patient, although established with the cardiologist (and practice), is new to the vascular surgeon.

Hope this helps.

 

[DJAuger]

Nephrology specialty to sub specialty within the same practice

Hello Pam,
We are having the same sort of issue within our nephrology practice with an internal referral from one of the nephrologists to transplant specialist who is also in our practice. They want us to bill the transplant nephrologist as a new patient however we are not finding any documentation to support this so we are looking for some help with this issue.

Thank you!
Diane A. COC

 

[CodingKing]

Hello Pam,
We are having the same sort of issue within our nephrology practice with an internal referral from one of the nephrologists to transplant specialist who is also in our practice. They want us to bill the transplant nephrologist as a new patient however we are not finding any documentation to support this so we are looking for some help with this issue.

Thank you!
Diane A. COC

I'd take the advice about seeing what the payer considers the specialty to be based on the providers enrollment. Looking at the CMS Taxonomy list. Nephrology is either Adult or Pediatric Nephrology , not much of a subspecialty breakdown.

 

[malinusky]

new patient visit

Hi Pam,

Slightly different scenario. The provider used to work at local hospital and was credentialed there as urgent care. He now has a private practice and is credentialed as a PCP and no longer seeing patients at the hospital. If he sees patients he saw at the hospital (less than the 3 years) in his private practice can he bill new office visit?


TIA

If they saw the same patient within three years, it doesn't matter if the provider himself changed specialties or subspecialties. They would be established patients.

If the doctor saw the patient within three years, (regardless of where seen--old practice, new practice, new specialty, new problem) it's an established patient.

The specialty/subspecialty comes into play in this way:

We have cardiologists and vascular surgeons in the same practice. The patient is established with a cardiologist, and develops varicose veins. The cardiologist sends the patient to his practice colleague, the vascular surgeon, who the patient has never seen before. The patient, although established with the cardiologist (and practice), is new to the vascular surgeon.

Hope this helps.

 

[CodingKing]

Hi Pam,

Slightly different scenario. The provider used to work at local hospital and was credentialed there as urgent care. He now has a private practice and is credentialed as a PCP and no longer seeing patients at the hospital. If he sees patients he saw at the hospital (less than the 3 years) in his private practice can he bill new office visit?


TIA

Same provider w/ face to face in last 3 years it's always established. The only way it would not be established is if it was more than 3 years ago or the previous encounter wasn't face to face, for example only billed for professional component of an x-ray or an ekg reading.