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Another New vs Est Visit, Subspecialties, Etc.

  1. Question Another New vs Est Visit, Subspecialties, Etc.
    Medical Coding Books
    I have an otolaryngology group that has different subspecialties in it (ear, oncology, etc) and I'm a little confused. They all share the same tax id. I was told I would be able to bill 2 visits to Medicare on the same day for my physicians because the 2 that the pt saw were of different subspecialties. That being said, I have a patient who was seen by one dr of one subspecialty in 2009 and then was seen again in 2010 by a physician of another subspecialty. Does this mean I can charge a new pt visit? As I said before, it's the same tax id, so I'm not really sure what I'm supposed to do. Any help would be greatly appreciated!!

  2. #2
    Flower City
    Default Sub-speciality - concurrent care
    I would bill a new visit for the initial visit with the sub-specialist. Be sure documentation supports the distinct differences in the problems accessed by the subspecialist.etc...and the medical necessity for the provider with the additional skill set to address a complex problem beyond what a "generalist" would. A bit long but hope it is helpful.

    Here is what NGS for Part B NYS says in there 12/16/09 Ask the Contractor Teleconference Q&A: If they're different specialties, it's a new patient, just like an initial visit would have been or a consult would have been before.

    (Caller) We have neurologists that might be a general neurologist but also they send it to their peer that specializes in MS.

    Response: Yes. One of the problems though that you're going to encounter, while this is a consultation, in the processing system these providers do not look any different. They're going to look identical. Your neurologist is still going to be a specialty 13 and you won't be able to tell. So you may see that your claim gets denied and you may have to come in on appeal for that. The important point is that this is a consultation that was required because you have somebody who is a recognized sub specialist.

    Contact your local carrier where you are located for their guidelines.

    This excerpt below doesn't address the Tax ID question specifically just the need for concurrent care services and billing for both services. If you bill for the initial visit and receive a rejection you can appeal using this guidance and the documented medical necessity from the provider.

    E. Concurrent Care
    Concurrent care exists where more than one physician renders services more extensive
    than consultative services during a period of time. The reasonable and necessary services
    of each physician rendering concurrent care could be covered where each is required to
    play an active role in the patient‟s treatment, for example, because of the existence of
    more than one medical condition requiring diverse specialized medical services.
    In order to determine whether concurrent physicians‟ services are reasonable and
    necessary, the carrier must decide the following:
    1. Whether the patient‟s condition warrants the services of more than one
    physician on an attending (rather than consultative) basis, and
    2. Whether the individual services provided by each physician are reasonable and
    In resolving the first question, the carrier should consider the specialties of the physicians
    as well as the patient‟s diagnosis, as concurrent care is usually (although not always)
    initiated because of the existence of more than one medical condition requiring diverse
    specialized medical or surgical services. The specialties of the physicians are an
    indication of the necessity for concurrent services, but the patient‟s condition and the
    inherent reasonableness and necessity of the services, as determined by the carrier‟s
    medical staff in accordance with locality norms, must also be considered. For example,
    although cardiology is a sub-specialty of internal medicine, the treatment of both diabetes
    and of a serious heart condition might require the concurrent services of two physicians,
    each practicing in internal medicine but specializing in different sub-specialties.
    While it would not be highly unusual for concurrent care performed by physicians in
    different specialties (e.g., a surgeon and an internist) or by physicians in different sub-
    specialties of the same specialty (e.g., an allergist and a cardiologist) to be found
    medically necessary, the need for such care by physicians in the same specialty or sub-
    specialty (e.g., two internists or two cardiologists) would occur infrequently since in most
    cases both physicians would possess the skills and knowledge necessary to treat the
    patient. However, circumstances could arise which would necessitate such care. For
    example, a patient may require the services of two physicians in the same specialty or
    sub-specialty when one physician has further limited his or her practice to some unusual
    aspect of that specialty, e.g., tropical medicine. Similarly, concurrent services provided
    by a family physician and an internist may or may not be found to be reasonable and necessary, depending on the circumstances of the specific case. If it is determined that
    the services of one of the physicians are not warranted by the patient‟s condition,
    payment may be made only for the other physician‟s (or physicians‟) services.
    Once it is determined that the patient requires the active services of more than one
    physician, the individual services must be examined for medical necessity, just as where
    a single physician provides the care. For example, even if it is determined that the patient
    requires the concurrent services of both a cardiologist and a surgeon, payment may not be
    made for any services rendered by either physician which, for that condition, exceed
    normal frequency or duration unless there are special circumstances requiring the
    additional care.
    The carrier must also assure that the services of one physician do not duplicate those
    provided by another, e.g., where the family physician visits during the post-operative
    period primarily as a courtesy to the patient.
    Hospital admission services performed by two physicians for the same beneficiary on the
    same day could represent reasonable and necessary services, provided, as stated above,
    that the patient‟s condition necessitates treatment by both physicians. The level of
    difficulty of the service provided may vary between the physicians, depending on the
    severity of the complaint each one is treating and that physician‟s prior contact with the
    patient. For example, the admission services performed by a physician who has been
    treating a patient over a period of time for a chronic condition would not be as involved
    as the services performed by a physician who has had no prior contact with the patient
    and who has been called in to diagnose and treat a major acute condition.
    Carriers should have sufficient means for identifying concurrent care situations. A
    correct coverage determination can be made on a concurrent care case only where the
    claim is sufficiently documented for the carrier to determine the role each physician
    played in the patient‟s care (i.e., the condition or conditions for which the physician
    treated the patient).
    Marianne Wink, RHIT, CPC, ACS-EM

  3. Default
    Actually, this makes a lot of sense. I can see where my one ENT is somewhat general, and then another of my docs specializes in the head/neck oncology. Thank you!

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