NGS changing processing of same day NP/PA claims

Is NGS your MAC?

Did you see their announcement that for claims processed on or after Sept 15, 2018, they will no longer deny claims for a second NP or a second PA of a different specialty, who sees the patient on the same day?

Here’s an example:

Patient sees a PA in Dermatology in the morning. In the afternoon, the patient sees a PA in Family Medicine.  Currently, the first claim processed by NGS would be paid and the second denied as a duplicate (two PAs in one day, even though different specialties).  NGS says that when appealed, the second claim is paid but they want to stop the extra work for practices and for themselves.

PAs are all enrolled in Medicare with a single specialty code, (97) regardless of the specialty in which they are working.

NPs are all enrolled in Medicare with a single specialty code, (50) regardless of the specialty in which they are working.

Now, practices must put the specialty code in the 2300/2400 STE segment loop, like this: SPEC 06 for cardiology or SPEC 02 for general surgery. (You can download the list at the end of this post.)

This change will be effective based on the date of claims processing, September 15, 2018, not date of service. You can’t re-submit claims that were previously denied, but can continue to appeal them.  NGS will not automatically re-process them.

NGS will also look at the diagnosis code that is submitted. The primary diagnosis code for the two providers needs to be different for the payment to process automatically.

What didn’t change?

The fact that all NPs are considered as one specialty and all PAs as one specialty in processing new and established patient visits.  In a multi-specialty group, that means a patient seen by a PA in Family Practice is considered established when seen by any other PAs in the group, regardless of specialty designation.

Summary of NGS change in claims processing

Effective date: Claims processed on or after September 15, 2018

Change: Will allow two NPs or two PAs working in different specialties to be paid without the need for appeal, in the same multi-specialty group or in different groups.

Diagnosis coding: The primary diagnosis code for each of the two claims can’t be the same.

Action item:  For NP/PA claims, add the specialty code in 2300/2400 STE segment loop for all claims, in this format:  SPEC 82.

CMS Specialty List

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