Wiki NURSE PRACTITIONER NEW PATIENT CLAIMS

[GALLAST]

Novitas Solutions, Jurisdiction JL, denies our Nurse Practitioner new patient claims if the patient has seen another nurse practitioner in the practice, New Patient Qualifications not met. After appealing with notes indicating why each nurse practitioner saw the patient, Novitas upholds the denial indicating that patient saw a nurse practitioner on another date, so patient is established within the practice and new patient qualifications were not met. Our coding team states that according to AMA guidelines, each NP saw the patient for a different specialty, therefore, new patient qualifications do apply. Novitas tells me that they follow CMS guidelines and that NPs are not credentialed as specialties. Does anyone know where I can find that information in writing?

 

[Pam Warren]

CMS does not recognize Nurse Practitioners with different taxonomy codes (like physicians do) based on different specialties that they might work in. From CMS' perspective, an ARNP is an ARNP period.

So if a patient sees a nurse practitioner for cardiology and later a NP for pulmonary in the same practice, they would be established patients, because CMS sees an NP as a single specialty.

 

[csperoni]

Actually, I don't think CMS clarifies this in black and white and leaves it to the MACs.
For example, my MAC (NGS) states this (click for link):
Please explain the new vs. established patient rules for NPPs (PAs and NPPs) working in different specialty areas.
Answer: NPs are designated by CMS as specialty 50, and PAs are designated as specialty 97. CMS, in consensus with AMA CPT, considers NPPs who are working with physicians as working in the exact same specialty or subspecialty as the physician. For example: a new patient visit by an NP working within internal medicine may be payable to the same group in which an NP working within cardiology has already been paid within three years. Additional information is required on NPP claims to allow these multiple first visits. When the additional information is not included on both claims, the second claim will deny and may be submitted as an appeal, with documentation of the first paid service along with the current service. Please refer to Nonphysician Practitioners – Reducing Costly Appeals; Increase Provider Revenue for NGS’ guidelines for NPP billing.

I could not find any similar statement on Novitas' website. I would note - when you are submitting claims for your NPs, you should be indicating who the supervising physician is for that service. That is what NGS uses to determine if an E&M meets new patient guidelines. It is also very helpful to include this information if your NPPs are seeing admitted patients and both work for a large multi-specialty group. A cardiology NP and a neuro NP might both see the same patient the same day. If you do not include the supervising physician on the claims, it would be denied as duplicate. If you do include the required information, both visits would be paid.