New Patient visits - Palliative Care to Hospice

hlmac6483

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I work for an organization that provides Hospice and Palliative Care services. We know that if we previously saw a patient in PC within the past 3 years, that we are not able to bill as a new patient if they re-admit to PC services. My question is if we have a patient in PC that is now Hospice appropriate, can it be billed as initial? We bill under the same Tax ID, but have different NPI and taxonomy codes for each program, and obviously, one is Part A and the other Part B.

On the same note, if we previously saw a patient for PC services during a hospital admission, but did not follow them on an outpatient basis, can we bill as a new patient 2 1/2 years later as an outpatient?

Thank you for any insight that may be provided.

HLM
 

lcohen4

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new paitent defintion

A new paitent, no matter whether PC or not, is determined based on the provider rendering services and/or providers of the same specialty in the same practice.

If an existing patient of Provider A has been seen by Provider A or by another provider of same speicalty in same practice within the last 3 years then it is not a new patient

Based on my experince, this applies in all circumstances in relationship patient/provider
 
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I work for an organization that provides Hospice and Palliative Care services. We know that if we previously saw a patient in PC within the past 3 years, that we are not able to bill as a new patient if they re-admit to PC services. My question is if we have a patient in PC that is now Hospice appropriate, can it be billed as initial? We bill under the same Tax ID, but have different NPI and taxonomy codes for each program, and obviously, one is Part A and the other Part B.

On the same note, if we previously saw a patient for PC services during a hospital admission, but did not follow them on an outpatient basis, can we bill as a new patient 2 1/2 years later as an outpatient?

Thank you for any insight that may be provided.

HLM

I was JUST working my way through a slightly similar situation a few days ago. Here's how it goes (this is from the MAC for my area):

"Medicare views physicians within the same group with the same specialty as the same person. We determine whether physicians are members of the same group based on the Tax Identification Number"

It goes on referencing a situation in which a business has two locations, a patient was seen at one as "new", then seen at the other and billed as "new"... "If both locations are under the same Tax ID, then Medicare will deny the second new patient visit procedure code received within the three-year period. Members who share the same Tax ID are part of the same group. The location of services does not make a difference."

Then this scenario:
"Q. Doctor A is new to our group. If a former patient sees Doctor A under our group, is this patient new or established? If the former patient has a visit with Doctor B, in our group with the same specialty as Doctor A, is the patient new or established?
A. If Doctor A sees his/her former patient, the service is an established patient visit. Doctor A's NPI shows the provider has seen the patient within the previous three years. If the patient sees Doctor B under the new group with the same specialty without seeing the Doctor A first under the new group, then the patient is considered a new patient because the Tax ID is different."

Bottom line being, for Medicare, the Tax ID is used to define a group. Although each program has its own NPI, the fact still remains that they both have the same Tax ID, therefore they are both considered as one group.

So in your case, no matter where your patients move to and from, they are always moving within a group. The only way to bill a patient as "new" is if they see a provider with a different specialty from ALL of the other providers that patient has seen in the previous 3 years within your group. With regards to the inpatient then outpatient, if the provider they are seeing as an outpatient has the same specialty as ANY of the providers that the patient saw while inpatient, then it's established.
 

hlmac6483

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Thanks for the replies. We found the same information regarding Tax ID, we're just confused over the whole "specialty/subspecialty" thing, considering the Hospice TAXONOMY CODE is totally different than the one for Palliative Care. So if the patient has been seen by our PC providers who all have an Internal Medicine specialty, then admits to our Hospice and is seen by the physician who has a specialty of OB/GYN, then we could bill that initial Hospice encounter as new?

It was a lot easier when Medicare allowed consult codes and I worked in Orthopedics for physicians who all had different subspecialties!
 
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When the whole NPI thing came about, I was (unfortunately) put into a special project group at the facility I worked for and all day we'd enter the applications for all the providers in our group, so that's where most of my knowledge comes from. Given that it's a very large teaching facility, you can only imagine how many providers we had to process through the NPI application, individually. Glad that's over, never wanna do that again. :(

Regarding specialty vs subspecialty... using Internal Medicine as an example, IM would be the specialty. Now, there's a massive number of types of IM providers (as you know). That's where subspecialty comes in; Geriatrics, Hematology, Oncology could all fall into the umbrella of IM. The key component to the whole specialty/subspecialty thing is based totally on what the providers have listed as their specialty and subspecialty within their individual NPIs. So when Medicare looks at a provider, they first see a Tax ID (which defines the group they are part of), then looks at that provider's NPI information to see what specialty and subspecialty (if applicable) they have. Because the application for an NPI includes that provider's taxonomy code(s), in a round-about way, they are looking at the taxonomy codes as well. They still have to pick the "primary" specialty/subspecialty if they submit more than one taxonomy code. This kind of explains it better:
https://www.cms.gov/medicare/provid...ation/medicareprovidersupenroll/taxonomy.html

If all the providers there are Internal Med, try drilling down to their subspecialty. I assume each of them has a particular area within IM that they specialize in...? If so, then that should be included in their NPI information as their subspecialty. In such a case, all of the providers may have an IM specialty, but if their subspecialties differ, then that's a whole different ballgame. Again, it all goes back to the NPI information for each individual provider. Generically speaking in a theoretical situation, let's say Dr. A primarily sees patients with breast cancer and Dr. B primarily sees patients with lung cancer. While treating a patient with breast cancer, Dr. A sees something that might indicate the cancer had metastasized to the lungs, so Dr. A sends the patient to Dr. B to evaluate it. They are both in the same group, they both have a specialty of IM, but if they have specialties related to the cancer type (breast vs lung), then one could make the argument that the patient would be new to Dr. B due to the different subspecialty. I don't know if such a set-up exists, but it's food for thought.

I can't answer your question about the admit and consult because there's NO consult codes for Medicare, as you mentioned :mad: I could probably work through that example if it was an admit other than hospice. Medicare and Hospice and I don't get along with each other very well.
 

thomas7331

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Actually, the information in the last post is not quite correct. Medicare carriers use the provider specialty code from the provider's 855 enrollment form, not the information from the NPI registry, to determine if two providers are or are not of the same specialty. Other carriers do however follow the NPI registry. I've had some success appealing Medicare new patient denials by submitting copies of the NPI registry that show that the providers have different specialties or sub-specialties, but this is a very time-intensive and unreliable way to get the claims paid.

This would apply to 'new' vs. 'established' codes, but codes with the description 'initial' are a different thing - you would bill an initial code is it's the first visit by the provider/specialty in that particular admission, you wouldn't apply the 3-year rule for those codes.
 
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Well then, it seems as though the facility I'm at is going to have to redo a whole lot of work.
 
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