Billing Questions - 2 random question

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SpineandWine

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1) In my group, we only had one anesthesiologist who used to do epidural steroid injections (under fluoro) - only interlaminar. Now that I'm coming in as the pain physician, he's stopping. When I see patients that have had prior ESI's by the anesthesiologist in clinic, can I bill as new patient evaluation even though he's seen them given he's the same speciality (he doesn't have clinic, only practices anesthesia but helps out when he can in fluoro room so he's never evaluated them in clinic)?

2) What about orthopoedic hand surgeon referring to orthopoedic spine - when the spine guy seems them, can he bill new patient evaluation or do they bill return visit? Anyone have good resource that looks into this?

BTW - we have a billing department consisting of 3 or 4 people and they for some reason, always minimize work and downgrade my level 4's to 3's, etc. They're very conservative (which is good because it protects us) but I think that seeing a patient in clinic for the first time and evaluating them from head to toe without any other pain physician (i'm the only board certified pain physician - only the general anesthesiologist who only helps out for fun) having done them should still count as new patient evaluation.

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If you’re under the same tax ID within the same group (same specialty) you can’t bill for new unless it’s been over 3 years
 
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Sort of a related question that I’ve gotten mixed answers on. I work in an ortho group. If a patient is sent to one of my colleagues who does an EMG (never bills an office visit eval, just the EMG), and then 6 months later sees me for back pain, is this a “new” or “follow-up” for me? Does it matter if the patient hadn’t been billed an office visit by someone in my same speciality, or is it just black and white if you’ve seen someone from the specialty before within 3 years then it’s a follow-up?
 
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If you’re under the same tax ID within the same group you can’t bill for new unless it’s been over 3 years
So tax ID and same specialty are what matters….

I hopefully won’t fall into this as he’s exclusively employed by hospital and I’m employed by physician group that contracts with hospital
 
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You are the only pain physician in the group. Every patient you see the first time needs to be billed as a new patient.
 
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1) In my group, we only had one anesthesiologist who used to do epidural steroid injections (under fluoro) - only interlaminar. Now that I'm coming in as the pain physician, he's stopping. When I see patients that have had prior ESI's by the anesthesiologist in clinic, can I bill as new patient evaluation even though he's seen them given he's the same speciality (he doesn't have clinic, only practices anesthesia but helps out when he can in fluoro room so he's never evaluated them in clinic)?

2) What about orthopoedic hand surgeon referring to orthopoedic spine - when the spine guy seems them, can he bill new patient evaluation or do they bill return visit? Anyone have good resource that looks into this?

BTW - we have a billing department consisting of 3 or 4 people and they for some reason, always minimize work and downgrade my level 4's to 3's, etc. They're very conservative (which is good because it protects us) but I think that seeing a patient in clinic for the first time and evaluating them from head to toe without any other pain physician (i'm the only board certified pain physician - only the general anesthesiologist who only helps out for fun) having done them should still count as new patient evaluation.
If different specialty then new visit. If the former anesthesia guy wasn’t a pain specialist it doesn’t matter if he saw them.

Difference between level 3 and 4 is big, would suggest you make a macro or scripted phrase or something to put in your level 4 visits and tell them to stop downgrading your billing.
 
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I am in a group with some neurosurgeons and pain guys. One of our PMR pain guys will occasionally refer patients to me for things he doesn’t do, such as kypho. Our billers told me that I can bill as a new patient since our specialty classification is not exactly the same - PMR pain vs. Anesthesia pain.
 
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Okay- reason I asked was that the ortho spine when he gets referred patients from like a hand surgeon, they downgrade his to level 3 despite having him having done different fellowship.

Can you give me a source on this? I can show this to billers for both myself and his situation
 
Okay- reason I asked was that the ortho spine when he gets referred patients from like a hand surgeon, they downgrade his to level 3 despite having him having done different fellowship.

Can you give me a source on this? I can show this to billers for both myself and his situation

That is because their base specialty is the same. Both are ortho.

Anesthesia and PMR are not the same as each other or ortho.
 
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Okay- reason I asked was that the ortho spine when he gets referred patients from like a hand surgeon, they downgrade his to level 3 despite having him having done different fellowship.

Can you give me a source on this? I can show this to billers for both myself and his situation
downgrading to level 3 because they are the same specialty is incorrect. The level of billing is based on complexity of medical decision making and that does not change because someone else saw them first. The hand surgeon still needs to review and interpret data.
 
Okay, but I’m anesthesia based pain, the other guy is anesthesiology
you are pain; that can be declared a different specialty as a subspecialty, but i would confirm.

otoh, if you are employed by this group, and he was directly employed by the hospital, most likely you will have 2 different tax IDs, so can bill them as new patients.

and agast is right - the MDM is based on various factors, none of which include who has seen the patient before.
 
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If you have different taxonomy codes, you can bill for new patient even if part of same group practice. For example, my partner is PM&R and I’m anesthesia. I think he’s registered as PM&R and I’m registered as Pain Medicine, so if he refers to me it’s a new patient for me.
 
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Okay, thank you everyone. I have talked it over. Will bill them as NP given different tax ID, confirmed with billing.
Regarding level 4 vs. 3, I've now been wording it in way to get credit for my 4's depending on how billing looks at them.
 
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If you have different taxonomy codes, you can bill for new patient even if part of same group practice. For example, my partner is PM&R and I’m anesthesia. I think he’s registered as PM&R and I’m registered as Pain Medicine, so if he refers to me it’s a new patient for me.


callmeanesthesia is correct here, it's all about taxonomy and how you are credentialed with payers, nothing to do with tax ID. Doc can change tax ID every year if they wanted to but that would t make patients new to the doc.

Here is a link that outlines it clearly.

 
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somewhat related question - can you bill an office visit code at a surgery center if you discuss a separate problem? example - did SIJ injection but discussed knee pain and set up for visco series? bill both the SIJ injection and office visit to discuss knee pain or are office visits not covered at surgery centers? i was 100% office based but joining new practice with surgery center so i dont know these things...
 
When you’re billing the office visit code are you planning on charging the patient a copay? If you’re legit considering it an office appointment you are required to do that.
 
I would think the copay could be something that they could charge after the fact, like if this scenario occurs then the practice sends out a bill for the co-pay. I don’t know though, that’s why I’m asking.
 
If another specialty physician in your practice saw that patient before, you can bill as a new patient. But if PA/NP of that another specialty physician saw that patient before, you can not bill as a new patient anymore because Medicare does not consider mid levels to be specialty specific. Hope it makes sense.
 
If another specialty physician in your practice saw that patient before, you can bill as a new patient. But if PA/NP of that another specialty physician saw that patient before, you can not bill as a new patient anymore because Medicare does not consider mid levels to be specialty specific. Hope it makes sense.

Can you provide a source for this? I have heard differing information, specifically that the APP is considered the same specialty as the physician who supervises them.
 
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