Yes, per CPT, the patient would new to the surgeon if no other physician of the same exact specialty in the same group practice has provided a professional service to the patient in the last 3 years. Medicare and some payers may consider some subspecialties to be in the same specialty but that should not be an issue here. CindyI have a Dr. 1 nephrologist who wants to refer an established patient to Dr. 2, a surgeon. Both doctors are in the same practice and share the same tax ID. Can we bill a new patient or consultation code for Dr. 2 if the patient is already established within the group?
Really we dermatology bill under the same tax id as our group that has Internal Medicine and gastro and if a patient see's one of those providers we can't bill a new patient E/M Code insurance denies the claim stating pt is established patient and need an established patient E/M Code to bill claim.Yes, per CPT, the patient would new to the surgeon if no other physician of the same exact specialty in the same group practice has provided a professional service to the patient in the last 3 years. Medicare and some payers may consider some subspecialties to be in the same specialty but that should not be an issue here. Cindy
Really we dermatology bill under the same tax id as our group that has Internal Medicine and gastro and if a patient see's one of those providers we can't bill a new patient E/M Code insurance denies the claim stating pt is established patient and need an established patient E/M Code to bill claim.
Thank you for your response so we use the same taxonomy and group npi for the group practice so maybe that is why ?From AMA guidelines:New and Established Patients
►Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services. A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. See Decision Tree for New vs Established Patients.
Unless your providers are credentialled incorrectly, dermatology is a different specialty (not even subspecialty) than either internal medicine or gastroenterology. Most commercial carriers go by taxonomy codes. Medicare uses a much more limited 2 digit specialty code. Dermatology is clearly different than IM or GI; there is no overlap. You might have issues with IM vs GI depending on how the GI lists their specialty. Some GIs credential as both IM and GI.
I am part of a huge (hundreds of providers)multi-specialty health care system. Excluding Medicare, we use taxonomy to differentiate new vs established.