New physician in group same tax id but different specialty

[jennifers]

New physician in group same tax id but different specialty - do we consider patient that new doc sees a new patient/new consult - or established because same tax id??? please advise again he is a different specialty
Thanks!

 

[CodingKing]

Same physician in last 3 years no matter what practice = Established.

Same specialty and subspecialty of a provider the patients is established to under the same TIN = Established

If the provider has not seen the patient elsewhere and is not the same specialty AND sub-specialty of another provider under the same TIN that has seen the patient then New.

 

[rejenia]

If the visit is within 3 years it would be established no matter what the specialty is they are under the same Tax ID. Insurance unfortunately look at that not the specialty. They would need different Tax id # in order to bill as new if this is the first time seeing the patient in the same practice. Hope this helps

 

[stephanie.moore@wdhospital.com]

We have Cardiovascular Providers and Vascular Surgeons in the same practice. They are credentialed with different specialties. We bill them as a new patient when they are being referred and they have not been seen by that specialty within the past 3 years.

 

[jennifers]

so we are orthopaedics and now getting a pain management doctor- if dr ortho send to dr pain new or established??? sorry I am confused

 

[thomas7331]

Medicare determines the provider's specialty based on how you complete the CMS-855I enrollment application and there is a separate specialty available for pain management on the form. So if your providers are enrolled with different specialties, you should not have a problem billing as a new patient if they are new to that particular specialty in your office. Other payers may have a different process - many will use the specialty that is listed on the provider's NPI registry but even that is not a certainty. In my experience, there is no sure way to know how a payer will handle new vs. established in every case. My approach has been to follow CPT guidelines and payer policies as best you can and then appeal any denials you may get.