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Billing as a subspecialist


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I work in a large orthopedic group under the supervision of an orthopedic surgeon with a subspecialty in sports medicine.  Since he has a subspecialty, if he sees a patient who has been seen by another provider( other than another sports med doc) in group within the last 3 years it is still considered a new visit. My doc feels that since I am an extension of him I should be able to do the same.  Anyone have any experience or thoughts about this scenario?

 

Thanks,

Brendan

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I work in a large orthopedic group under the supervision of an orthopedic surgeon with a subspecialty in sports medicine.  Since he has a subspecialty, if he sees a patient who has been seen by another provider( other than another sports med doc) in group within the last 3 years it is still considered a new visit. My doc feels that since I am an extension of him I should be able to do the same.  Anyone have any experience or thoughts about this scenario?

 

Thanks,

Brendan

This is a tricky question. I had to spend a lot of time on this when I owned a practice in a subspecialty. The rule for "New Patient" billing by CMS is here. Private insurers default to CMS rules. So, as you know, if a patient is seen face to face within that speciality or subspecialty group within the past 3 years, they cannot be billed as a new patient for a subsequent visit. Before 2012 Sports Medicine was not recognised by CMS but then that changed, see here. So before this went into effect, if any orthopedists in your group had seen the patient within the past three years, then neither you nor your SP could bill as a NP. But now you can, if, you are working exclusively under that SP. If you also worth for one of the orthopedist and they sent you a patient, you cannot bill as a NP.  I work in the subspeciality of Headache Medicine. CMS has NOT recognized this as a supspeciality yet, like they have Sports Medicine. So, when one of the neurologists in my group refers a patient to me, and if that patient had been seen by him, face to face, within 3 years, I cannot bill as a NP. So, I see your SP as being correct in your case, unless you also work for one of the orthopedists, then it could get tricky. I got audited by CMS over this situation, where I moved to a different practice with a new SP in a subspeciality and billed as NP those patients I had seen in a different practice in a different subspeciality. I still think I was correct but CMS ruled that those were not NP because I had seen them, myself, within the past three years even though I had never seen them in this new practice. I had to pay them back about 5 grand. I think if I had the resources to take them to court I would have won, but it would have cost me much more than 5 grand.

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It gets tricky due to different language used in the CPT guidebook versus the CMS guidelines.  The CPT handbook specifically states that PA's should be regarded in the same subspecialty as their physicians.

 

"A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years."

 

"When advanced practice nurses and physician assistants are working with physicians, they’re considered as working in the exact same specialty and subspecialities as the physician. " 

 

However this specific language is not listed in the CMS guidelines.  

 

"A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years."

 

According to my billing department, with medicare it depends on the providers listed specialty.  In the case of a PA medicare only recognizes a Physician Assistant but no specialty.

 

In my case I work exclusively for a sports medicine orthopedic doc, according to the CPT guidebook it seems clear that I should be able to bill for a new patient for someone who was seen in my group by a general orthopedist within the past 3 years.  However without the specific language in the CMS guidelines, my billers say I can't bill the visit as a new.  Even though medicare is a small component of my practice, my billers say that most payers will follow medicare guidelines.  I find it very confusing and frustrating.  

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You are right in your observation that it is confusing. It IS confusing. That is why in my case with the CMS reviewers (private company paid by CMS to find "fraud" and they get a % of what they recover) I think I could have taken them to court and won. I think it is a huge mistake that we allow us to defined as a speciality of "Physician Assistant" but is how CMS defines us. Yet, speaking out of the other side of their mouths they say our specialty is defined by our SP's speciality. 

 

In your case, if the Sports Medicine guy is your only SP (and none of the orthopedists) I would agree with your SP that a new patient is a new patient in your subspecialty.  But if any of the Orthopedists (non-sports medicine) sends you a patient and they are also listed somewhere as your SP, then you cannot bill as a NP. However, if you are the first contact in your subspecialty and your SP is only in Sports Medicine, then  you should be able to bill as a NP. This does not mean that one of these private "watch dog" for profit reviewers might argue against that billing, and they might demand repayment, you will have the chance to appeal. Of my 10 cases filed against me over NP billing, I was able to successfully appeal about 4 of them. If Headache Medicine was a recognized subspecialty as Sports Medicine is, I am confident I could have over-turned all 10. But even the reviewers were confused by the CMS wording. So it is damn confusing. If I would king of the PA world I would fight to change our "speciality": name by CMS to our real speciality, not "Physician Assistant."

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