Wiki Two providers, different specialty, same day, same patient

[nolanspade]

Hello, I'm billing for a new patient (both 99204) that saw our hand surgeon (recognized subspecialty of orthopedics) and our spine surgeon (orthopedics) on the same day. I am wondering what, if any, modifier I should use?

Thanks for your help!

 

[csperoni]

If the providers are properly credentialed under the appropriate specialty/subspecialty, you should not need any modifier. If the insurance were to deny, I would submit a letter showing the different subspecialties.

 

[amyjph]

Agree, it all depends on how they are credentialed and taxonomy.
I had some ortho providers that were sports med and spine think they were credentialed differently but found they were all under only the general physicians/orthopedic surgery instead. So one had to be established and we would choose whoever saw the patient first as new and then the other established. I have also found some payers don't care about the taxonomy and will deny two new E/M on the same date under the same EIN even if the providers are credentialed differently and have different taxonomy codes.

https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/medicare-provider-and-supplier-taxonomy-crosswalk/data

 

[jkyles]

Hello, I'm billing for a new patient (both 99204) that saw our hand surgeon (recognized subspecialty of orthopedics) and our spine surgeon (orthopedics) on the same day. I am wondering what, if any, modifier I should use?

Thanks for your help!

It depends - Medicare does not recognize sub-specialty. For private payers you'll need to check the plan to see whether it has similar restrictions.

 

[csperoni]

A good modifier to help indicate they are separate visits is XP - Separate practitioner, a service that is distinct because it was performed by a different practitioner.

While -XP would seem like a correct definition, per codify, -XP is not a valid modifier on E&M services (nor any of the -X___ modifiers).

 

[amyjph]

While -XP would seem like a correct definition, per codify, -XP is not a valid modifier on E&M services (nor any of the -X___ modifiers).

I agree. https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xepsu.pdf

 

[nolanspade]

It depends - Medicare does not recognize sub-specialty. For private payers you'll need to check the plan to see whether it has similar restrictions.

Actually, hand surgery is the one sub-specialty of orthopaedics that Medicare recognizes. It is also a sub-specialty of plastics, I believe. If you look up the Medicare specialty codes Medicare Specialty Code Look-up of your providers, you, anyone that is different is a recognized specialty/subspecialty by Medicare - that's their official provider look-up site. Here is another resource to look up the actual specialty codes As mentioned, each of the codes listed there by Medicare is recognize. I point you towards 20, 40, 44. This code-set is Medicare's version of taxonomy codes, I've learned from our credentialing department. When filling out the online 855, the provider has to be associated with one of these.

 

[nolanspade]

While -XP would seem like a correct definition, per codify, -XP is not a valid modifier on E&M services (nor any of the -X___ modifiers).

In my ignorance, I had originally submitted the claim that way, and the claim with XP was denied for the XP. The other contributors in the string are correct - the X's don't apply to E/M codes.