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Denials for duplicate provider services under one tax ID number

  1. Default Denials for duplicate provider services under one tax ID number
    Medical Coding Books
    We are a large Multispecialty Practice under one Tax Id number. We are experiencing some payer problems such as:

    1. Payers denying the claim stating it is within global period, even though a different physician than the surgeon is seeing patient during that global time.

    2. If a patient sees one physician let's say a urologist that is in one practice and then the patient decides to see a different urologist that is in a toltally different practice, the insurance companies are denying the new patient visit amount. Payers are doing this to us even when it is a different Taxonomy/modality.

    Are there any other group practices out there that are set up this way and if so, how are you handling these issues?

    Thanks for the info!
    Linda Ferreyra, CPC
    Director of Central Billing office
    Regional West Physicians Clinic
    Scottsbluff, Nebraska

  2. #2
    Default Denials
    Hi Linda,

    First, if a different physican in the same group (under same tax ID#) other than the surgeon sees a patient within a global period for a different problem you need to modify the service to indicate the difference to the insurance company. If the other physician is seeing the patient as a follow up for the surgery you will not be paid because it is within the global period even though a different physician is performing the follow up care.

    If there are 2 specialist that operate under the same tax ID number they can only bill for a new patient level once even though there are two different doctors at two different locations. They are considered part of the same group and they are the same specialty. The patient is considered "new" only between specialties, not between two of the same specialty in the same group. You refered to different practices. Did you mean two different locations, two different doctors, but the same group (tax ID)?

    Hope this helps.

  3. Default denials
    we have seen the same thing with denials because we are a medical group of over 100 providers of different specialties all under one tax id. Typically we will file an appeal stating that there were two or more providers involved and the specialty that they represent. We also explain why more than one provider saw the patient. With this we are usually able to get paid for all providers.

  4. #4
    Like readingfool we also have many different specialties under same tax id it makes our job challenging... but we do get paid (not if same specialty)
    Colleen CPC

  5. #5
    Just a quick question. Is your group NPI set up with a taxonomy code of Multispecialty or Single Specialty group? If your group NPI is set up as single specialty then they will only pay for one physician per day regardless of the specialty.
    TJ Smith, CPC
    Cheyenne Physicians Group
    Cheyenne, WY

  6. Wink
    I work for a Urology group. We have physicians that specialize in different surgical procedure. I agree with Christine, you can only bill for a new pt visit every three years. Now if the patient goes to a different location the other physician cannot bill for a new patient. It would be wise if the doctor billed for a consultation for the patient first visit. When I work for a Dermatology group we had a doctor the specialize in MOHS surgery. if the patient came in for his/her regular visit and then had to f/u with the mohs surgeon you can bill for the same visit. You would file your claim with procedure notes, also I believe there is a modifier you can add to the charge.

    Hope this help!


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