Wiki Optima Denial: rebill as established

[1C2P3C]

I am in a group practice with two specialties, pulmonology and sleep. I keep getting denials for patients that we are billing as new because it is the first time they are seen on the pulmonary side and all other visits are on the sleep side and vice versa. Advice is appreciated.

 

[thomas7331]

I would recommend starting by contacting the payer that is making these denials and find out if one of the providers is perhaps enrolled incorrectly or assigned to an incorrect specialty in the payer's system, and if so, is it something that they would be able to correct. You need to know this in order to be able to determine the root cause of why these claims are being denied and what your best course of action will be.

If they payer has made an error, then they should reverse these denials for you. But if they insist the denials are correct, then you have a choice: you can try to appeal the denials with documentation that shows that the two providers are of different specialties , or you can change the codes and rebill as established patients. Depending on the payer and whether or not the appeals are effective, it may end up being simpler and more cost-effective to just rebill the claims and code future visits by patients with this payer as established going forward.

 

[amyjph]

Agree. It depends on how the provider is credentialed. You may think they are different subspecialties but it depends on the taxonomy. Also, some payers don't recognize this and if it's the same group Tax ID, they see it as the same and don't recognize new for a different subspecialty within three years.

Navigate the New vs. Established Patient Decision Tree

Selecting the correct code for many evaluation and management (E/M) services starts with determining whether a patient is new or established, as defined by CPT® guidelines.

www.aapc.com

 

[TThivierge]

Jen4cPc,
The insurance companies may look at if patient seen first time by either doctor AT SAME OFFICE LOCATION despite differ medical problems. Then next time bill this same patient as established. Also pulmonology involves sleep apnea and insomnia due to sometime breathing, psych head or medication issues. Another thing I learned with billing for sleep apnea or OSA sleep tests is bill day of interpretation NOT day got sleep study test. Add to if the patient is referred from another practice (examples Psych or Family Medicine )ensure put referring doctors name on claim field.
But contacting the payer and checking out CMS website help you too
I hope I helped you though!
Lady T

 

[1C2P3C]

Thanks for all the replies. It is really helpful.