Wiki New vs Established for Midlevel

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mykajens

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Hello! I have 2 midlevel providers who cover multiple areas. If they were to see a patient in a WIC setting, then see them another day as a patient being seen for the first time in Ortho, is the ortho visit new or established? I haven't been able to find an answer for this. Thank you for your advice!
 
mykajens said:
Hello! I have 2 midlevel providers who cover multiple areas. If they were to see a patient in a WIC setting, then see them another day as a patient being seen for the first time in Ortho, is the ortho visit new or established? I haven't been able to find an answer for this. Thank you for your advice!
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Billed under the same tax ID would be established. We have 5 nurse practitioners and have to bill visits as established if the patient has been seen by any other nurse practitioner from our hospital in the last 3 years no matter what specialty they are in.

Hope this helps.
 
My understanding for ACPs (including NPs) is that they are considered working under the specialty of their supervising provider. I work for a very large healthcare organization with hundreds of providers. An NP in a cardiology office may bill as a new patient even if the patient saw an NP from gastro.
Now if the same NP works Monday/Wednesday in cardio and the rest of the week in gastro, if it is the same actual provider, then the specialty is irrelevant.
I am interpreting your specific scenario as the patient is seen by NP1 in WIC setting (guessing as obgyn??). Then a week later, sees NP2 in ortho. If so, then that should be new patient. That is how I would code and if denied, submit an appeal letter showing the different supervising physician specialty.
 
Can be very confusing. It can depend on how the payer views subspecialty designation, if they follow CMS, if they have their own rules where it only goes by Tax ID or NPI, etc. I have worked in some large groups where to streamline, the NP/PA would bill established if the patient was seen in the group by anyone within the past 3 years. I have also seen where coders had to figure out if the patient had been seen by the same specialty/subspecialty and who the supervisor was, etc. It can get very convoluted depending on the group size and composition. Some payers don't care about the taxonomy and only look at Tax ID or group NPI. It can also depend on how providers were credentialed and if the coder doesn't actually know or check that, it can be incorrectly coded also.

I think, in your question, you are asking if the same NP sees the same patient under two different subspecialties, can they bill new under both? If that is the case, I probably wouldn't do two new E/Ms. The mid-level provider has already seen the patient face-to-face regardless of the subspecialty they are working in that day. If it was two different NPs, maybe, but that depends on all the stuff above. If you are in a large group there should be a policy about this. It can take a really long time to scour medical records and for a coder to try and figure out if it is new vs. established. Could money be left on the table? Maybe. However, billing new when it should not be can also cause rejections, denials, and extra work on the back end.

Examples: Non-Physician Practitioner in Multi-specialty Group - JE Part B - Noridian

Q: Will UnitedHealthcare reimburse New Patient CPT codes for Nurse Practitioners/Physicians Assistants reporting under providers of different specialties but same TIN?
A: No. Nurse Practitioners (NPs) and Physicians Assistants (PAs) are credentials of the practitioner (such as MD, DO), they are not considered specialty designations. Therefore, if a current claim comes in for a new patient E/M provided by an NP and there is a claim in history provided by an NP, with the same TIN, the current claim will deny, allowing the provider to review their documentation and resubmit with the appropriate established E/M service.

CMS manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

This may be an older post, but has really good explanations:

New versus established patient visits - CodingIntel

There are other articles on CodingIntel about the difference between new and established patients, and the rules haven’t changed, but that doesn’t mean it is always clear. Medicare definition "Interpret the phrase “new patient” to mean a patient who has not received any professional services...
codingintel.com codingintel.com
Specifically, this part:
"Commercial insurers usually follow the CPT® rule and consider the NPP as being of the exact same specialty as the physician (s) with whom they practice. As mentioned, insurance policies sometimes have a different deductible and different benefit categories for primary care and specialty services. The company considers the PA who works in an orthopedic office as a specialty provider and the PA who works in a Pediatric practice as a primary care provider. This allows them to process claims depending on if the visit is done in a primary care or specialty practice.

However, since Medicare considers all PAs of the same specialty, and all NPs of the same specialty, they process claims differently. In a multi-specialty group, if a patient sees an NP in oncology, that patient will be considered established if seen by any other NP working in any specialty. This can be challenging in a multi-specialty group if new patients are seen by NPs and PAs."
 
amyjph said:
Can be very confusing. It can depend on how the payer views subspecialty designation, if they follow CMS, if they have their own rules where it only goes by Tax ID or NPI, etc. I have worked in some large groups where to streamline, the NP/PA would bill established if the patient was seen in the group by anyone within the past 3 years. I have also seen where coders had to figure out if the patient had been seen by the same specialty/subspecialty and who the supervisor was, etc. It can get very convoluted depending on the group size and composition. Some payers don't care about the taxonomy and only look at Tax ID or group NPI. It can also depend on how providers were credentialed and if the coder doesn't actually know or check that, it can be incorrectly coded also.

I think, in your question, you are asking if the same NP sees the same patient under two different subspecialties, can they bill new under both? If that is the case, I probably wouldn't do two new E/Ms. The mid-level provider has already seen the patient face-to-face regardless of the subspecialty they are working in that day. If it was two different NPs, maybe, but that depends on all the stuff above. If you are in a large group there should be a policy about this. It can take a really long time to scour medical records and for a coder to try and figure out if it is new vs. established. Could money be left on the table? Maybe. However, billing new when it should not be can also cause rejections, denials, and extra work on the back end.

Examples: Non-Physician Practitioner in Multi-specialty Group - JE Part B - Noridian

Q: Will UnitedHealthcare reimburse New Patient CPT codes for Nurse Practitioners/Physicians Assistants reporting under providers of different specialties but same TIN?
A: No. Nurse Practitioners (NPs) and Physicians Assistants (PAs) are credentials of the practitioner (such as MD, DO), they are not considered specialty designations. Therefore, if a current claim comes in for a new patient E/M provided by an NP and there is a claim in history provided by an NP, with the same TIN, the current claim will deny, allowing the provider to review their documentation and resubmit with the appropriate established E/M service.

CMS manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

This may be an older post, but has really good explanations:

New versus established patient visits - CodingIntel

There are other articles on CodingIntel about the difference between new and established patients, and the rules haven’t changed, but that doesn’t mean it is always clear. Medicare definition "Interpret the phrase “new patient” to mean a patient who has not received any professional services...
codingintel.com codingintel.com
Specifically, this part:
"Commercial insurers usually follow the CPT® rule and consider the NPP as being of the exact same specialty as the physician (s) with whom they practice. As mentioned, insurance policies sometimes have a different deductible and different benefit categories for primary care and specialty services. The company considers the PA who works in an orthopedic office as a specialty provider and the PA who works in a Pediatric practice as a primary care provider. This allows them to process claims depending on if the visit is done in a primary care or specialty practice.

However, since Medicare considers all PAs of the same specialty, and all NPs of the same specialty, they process claims differently. In a multi-specialty group, if a patient sees an NP in oncology, that patient will be considered established if seen by any other NP working in any specialty. This can be challenging in a multi-specialty group if new patients are seen by NPs and PAs."
Click to expand...
1) I definitely agree if it's the same clinician (regardless of specialty), the second visit is established.
2) If it is 2 different NPs, I interpret CMS guidelines as it may be billed as new for a different subspecialty. Yes, commercial carriers may have policies that differ, and apparently UHC is one of them. However, per the link you provided to Noridian, they WILL pay for 2 different NPs practicing in 2 different specialties. There are instructions that as of 03/01/2022, the NPPs should be properly submitting specialty information on their claims to avoid denials. If the information is not properly submitted and the the claim is denied, it may be appealed.
Specifically:
"CMS editing only permits one new visit per provider specialty type within a group over a three-year period. Since NPs and PAs are two different provider designations, new visits by each within a three-year period may be payable. If the subspecialty information is missing on the original claim causing a denial, it may result in a provider submitting an appeal. However, Noridian's goal is to reduce the number of submitted appeals when the specialty and reason for the visit are different between the two E/M services. By placing the subspecialty in box 19 initially, it reduces the probability of a denial.
Example: if the patient was seen in a multi-specialty practice as a new patient by a specialty 50 working within family practice (specialty 11) and then seen within three years by a specialty 50 working within cardiology (specialty 06), the second new visit would be denied without the subspecialty information included in the comment field. If the documentation submitted with an appeal supported a medically necessary service addressing a distinctly separate problem, the second service may be payable on appeal. It is permissible to bill these services as subsequent visits, since they are considered as subsequent care by a same-specialty provider in the group. If the provider submitted both claims with the subspecialty information included in box 19, the claim would not have initially denied."

My MAC also allows new patient NPP based on the specialty of the supervising physician but specifies this ONLY applies to NGS and to consult the appropriate MAC if not NGS. Honestly, I thought this was CMS guidance and not MAC specific, but it might be.
 
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csperoni said:
1) I definitely agree if it's the same clinician (regardless of specialty), the second visit is established.
2) If it is 2 different NPs, I interpret CMS guidelines as it may be billed as new for a different subspecialty. Yes, commercial carriers may have policies that differ, and apparently UHC is one of them. However, per the link you provided to Noridian, they WILL pay for 2 different NPs practicing in 2 different specialties. There are instructions that as of 03/01/2022, the NPPs should be properly submitting specialty information on their claims to avoid denials. If the information is not properly submitted and the the claim is denied, it may be appealed.
Specifically:
"CMS editing only permits one new visit per provider specialty type within a group over a three-year period. Since NPs and PAs are two different provider designations, new visits by each within a three-year period may be payable. If the subspecialty information is missing on the original claim causing a denial, it may result in a provider submitting an appeal. However, Noridian's goal is to reduce the number of submitted appeals when the specialty and reason for the visit are different between the two E/M services. By placing the subspecialty in box 19 initially, it reduces the probability of a denial.
Example: if the patient was seen in a multi-specialty practice as a new patient by a specialty 50 working within family practice (specialty 11) and then seen within three years by a specialty 50 working within cardiology (specialty 06), the second new visit would be denied without the subspecialty information included in the comment field. If the documentation submitted with an appeal supported a medically necessary service addressing a distinctly separate problem, the second service may be payable on appeal. It is permissible to bill these services as subsequent visits, since they are considered as subsequent care by a same-specialty provider in the group. If the provider submitted both claims with the subspecialty information included in box 19, the claim would not have initially denied."

My MAC also allows new patient NPP based on the specialty of the supervising physician but specifies this ONLY applies to NGS and to consult the appropriate MAC if not NGS. Honestly, I thought this was CMS guidance and not MAC specific, but it might be.
Click to expand...
Oh yes, saw that about the different NP and box 19. I'm not saying it can't be done, just that it has to be done by what the specific payer being billed follows. I have just seen so many headaches and confusion over it in the past. Especially when NPPs switch around and may go between different parts of the same group. If the practice or group has everything in order with the practice management system, edits, policies, etc. it can definitely be done. But also, I think the OP was talking about the same NP seeing the same patient under two different specialties and billing two new EM.
 
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