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Thread: New or Established?

  1. #11
    Join Date
    Apr 2007
    Boston, MA


    AAPC: Back to School
    In order to be sure if this is a same or different specialty you need to see how these providers are credentialed with the carrier. If they are all credentialed to the same specialty, regardless of their subspecialty, then it is established. If they are credential to different specialties then it is new (all other conditions for new must be met, of course). For example, if Drs. B and C are credentialed as Neuro-surgeons, and Dr. A is credentialed as oncologist then it is a new pt for Dr. A (same group, different specialty).
    Karolina, CPC, CPMA, CEMC

  2. #12
    Join Date
    Apr 2007
    Columbia, MO


    I think this is a matter of interpretation also. Here is how I have run in to this which then forms my interpretation.. I work with one physician group, they are organized as a group practice under the same tax ID... different specialties, however when the ortho doc billed as a new pt for a pt estb with family practice, the claim was denied as the patient was establishe to the group practice. A different group I work with all orthos in the same building all have their own individual tax ID but they all practice in the same building under the same business name, when Dr. B sees a pt having already been seen by Dr A, the claim for new patient was denied as the patient was already estb with the "practice". So when I see same group practice (same physician specialty) I take it that they are covering both types of scenarios. Your interpretation is that the parenthetical reference is a clarification for group practice. And now we are all confused!
    Last edited by mitchellde; 06-11-2009 at 04:48 PM. Reason: clarification

  3. #13


    I appreciate all the responses. Just to add a little more confusion...it's been suggested to me that perhaps the specialty in my case would be Interventional Radiologist vs. Diagnostic Radiologist rather than cancer-treating doctor vs. neuro-treating doctor since both are Interventional Radiologists?

    While my IR doctors have different areas of expertise, I guess the most explicit we get when credentialing them is whether they are interventional or diagnostic. Although all interventional docs are called upon to help read xrays too. And that leads me to wonder if radiology groups have specialties at all.


  4. #14
    Join Date
    Apr 2007


    I would suggest you check with your carrier on how they are credentialed.

    I have worked for large multispecialty groups, one had over 200 providers in 27 different specialties and the current has approx 500 providers and I am not sure how many specialties (thankfully I am only responsible for 7 different specialties at this time). As I stated earlier WPSMedicare advised us that if our CVT PA does a consult inpatient and has the patient follow-up outpatient with the CVT surgeon they work for, it is a new patient because they consider them different specialties.

    All my providers have the same tax id# and I have never had a problem with any insurance, be it governmental or commercial, rejecting new patient visits for different specialties.

    This is from CMS

    "Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group."

    Laura, CPC
    Last edited by LLovett; 06-12-2009 at 07:47 AM.

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