Wiki New patient ? Pt seen OD, then goes to MD in same practice

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kclonch

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I work for an Ophthalmology/Optometry practice. If a patient has only seen an OD in the practice, then sees an MD (for cataract surgery or oculoplastics consult, etc) - can the MD bill as a new patient? Would be under the same tax id#, but, obviously, different taxonomy #'s.
 
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I disagree. Different subspecialty is a new patient.
From AMA https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
"A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years."
 
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So that is something that just changed this year. I had not heard that yet, so thank you! (I wonder how many insurance companies have not heard of this yet and will deny claims ....ughhh). Thanks!
 
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csperoni said:
I disagree. Different subspecialty is a new patient.
From AMA https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
"A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years."
Click to expand...
Most insurance companies do not recognize the newer sub-specialty taxonomies and especially with same tax id. This would take a lot of back end work to get paid if at all, most practices just don't have the resources to do this.
 
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saddie2k said:
Most insurance companies do not recognize the newer sub-specialty taxonomies and especially with same tax id. This would take a lot of back end work to get paid if at all, most practices just don't have the resources to do this.
Click to expand...
The original post indicated the providers are different taxonomies, so for the question posed it is new patient.
If your providers are credentialed incorrectly, this should be corrected. Credentialed as the wrong specialty could have a larger scope than only whether you bill new/established. It could impact what procedures the insurance will authorize for you. Patients will contact you when they are looking for a specific type of provider that you are not. It could even impact your fee schedule. I agree that credentialing can be a lot of work, but I think it's important.
If they are an unofficial subspecialty, or a subspecialty that the insurance company does not recognize, or simply have expertise in an area that the other provider does not, then it would be established.
 
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I just happen to view this today and I know this to be true, because it happened to me, if you both have the same tax ID # that is what is causing you NOTE to be able to bill as a new patient visit under each provider. The tax ID #'s are how you are paid. Do I think this is wrong YES! Check with the insurance companies credentialing department to see if there is anything you can do concerning that issue for the future.
 
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