Question Medicare is denying a patient's claim as being established when the patient was seeing a new provider of a different specialty at our facility

carlystur

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Should this be appealed with no change? If so, should anything go with the appeal? If no appeal and update the claim, why?
 

csperoni

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Question number 1 is how is each of these physicians credentialed with Medicare?
If each is in fact a different taxonomy, then it should be appealed with that explanation.
If not, then a corrected claim as established should be submitted.
Some specialties, there are recognized "official" subspecialties, and some there are not.
For example, there may be an orthopedist that specializes in shoulder. That is not a recognized subspecialty, and if another orthopedist in the same group referred the patient, it is established.
If the 2nd orthopedist specializes in hand surgery and is credentialed as that taxonomy, then new patient is appropriate.
 

carlystur

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Question number 1 is how is each of these physicians credentialed with Medicare?
If each is in fact a different taxonomy, then it should be appealed with that explanation.
If not, then a corrected claim as established should be submitted.
Some specialties, there are recognized "official" subspecialties, and some there are not.
For example, there may be an orthopedist that specializes in shoulder. That is not a recognized subspecialty, and if another orthopedist in the same group referred the patient, it is established.
If the 2nd orthopedist specializes in hand surgery and is credentialed as that taxonomy, then new patient is appropriate.
Our regular providers are neurosurgeons and this new provider specializes in Pain Management. Does that count? Thanks, I'll take a look at the link!
 

carlystur

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He says he is, but maybe the encounter wasn't actually for pain management in the first place. It's a follow-up for an injection this doctor did. Does that make a difference?
 

csperoni

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Technically, the specialty/subspecialty is what makes the determination.
I can also tell you if I asked my physicians what taxonomy they credentialed with for Medicare, they would have no clue. The NPI data is an indicator (but not always what was put on the Medicare application). I would first try asking whoever at my facility does credentialing. Second try would be checking with my MAC.
 

carlystur

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Technically, the specialty/subspecialty is what makes the determination.
I can also tell you if I asked my physicians what taxonomy they credentialed with for Medicare, they would have no clue. The NPI data is an indicator (but not always what was put on the Medicare application). I would first try asking whoever at my facility does credentialing. Second try would be checking with my MAC.
That's what I thought about the specialty/subspecialty. Our practice manager is now involved in this and has the taxonomy codes for the various providers here. I believe he is saying that our new provider is credentialed with Medicare. I'm waiting to hear back from him at the moment since he told me that he's checking with other people he knows in the medical field about how to handle this.
 

carlystur

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So, I have an update. The patient came previously to the same pain management provider for an injection. I didn't think about that counting in this, so in that situation, it's then considered an established patient at the next appointment with the provider who did the injection. He did the new patient encounter with the injection.
 
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