Wiki New vs Established

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thice

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Hello. What are the specific rules for new vs established patients for physicians within the same practice, meaning the same tax id. I work for a large ortho group with several different specialties (ex, spine and hand). My hand doctor insists she can charge a new patient level on a patient who has been seen within the last three years since she has a different sub specialty then the other ortho doctors. Is she correct?
 
Check CPT guidelines. It does indicate same speciality and same subspecialty. So if it is a different sub specialty It apears she is correct. The decision tree in the guidelines is a quick resource.
 
New vs. Established

Review page 11 of your CPT book. Even though your Specialist have different specialties they are still practices under the same scope of care making your patients established going from one Ortho to another.
 
New vs Est

Your physician would be correct, as long as the subspecialties has a different taxonomy code. But most important is that the provider was credential with the subspecialty taxonomy.

20
Physician/Orthopedic Surgery
207X00000X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery
207XS0114X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Adult
Reconstructive Orthopaedic Surgery
207XX0004X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Foot and Ankle
Surgery
207XS0106X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Hand Surgery
207XS0117X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Orthopaedic
Surgery of the Spine
207XX0801X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Orthopaedic
Trauma
207XP3100X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Pediatric
Orthopaedic Surgery
207XX0005X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Sports Medicine

You can find the taxonomy listing on CMS website: http://www.cms.gov/Medicare/Provide...iderSupEnroll/Downloads/TaxonomyCrosswalk.pdf
 
Last edited:
CBaer said:
Your physician would be correct, as long as the subspecialties has a different taxonomy code. But most important is that the provider was credential with the subspecialty taxonomy.

20
Physician/Orthopedic Surgery
207X00000X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery
207XS0114X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Adult
Reconstructive Orthopaedic Surgery
207XX0004X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Foot and Ankle
Surgery
207XS0106X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Hand Surgery
207XS0117X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Orthopaedic
Surgery of the Spine
207XX0801X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Orthopaedic
Trauma
207XP3100X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Pediatric
Orthopaedic Surgery
207XX0005X - Allopathic & Osteopathic Physicians/Orthopaedic Surgery, Sports Medicine

You can find the taxonomy listing on CMS website: http://www.cms.gov/Medicare/Provide...iderSupEnroll/Downloads/TaxonomyCrosswalk.pdf
Click to expand...


I'm glad I saw this; I posted a similar question recently, but regarding Neuro, not Ortho. So based on this info, Ortho MD's can register with CMS as a subspecialist under the taxonomy codes listed above...hand, spine, sports meds, etc. Since Neuro isn't broken down the same way (MS, Movement Disorders, Sleep Medicine, Epilepsy), they can't register with CMS as a subspecialist? Am I understanding this correctly? Appreciate any guidance anyone can give with this.

Thanks!!
 
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