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March 29, 2023

Physician specialty codes and claims processing

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When physicians enroll in Medicare, they self-elect their specialty designation. In the enrollment process, there are fields to indicate primary and secondary specialty. Nurse practitioners and physician assistants don’t indicate the specialty in which they work for Medicare, although they do when enrolling in commercial plans. CPT says that when advance practice practitioners are working with physicians, they are considered to be the same specialty as the physician.

Medicare and commercial payers use the primary specialty designation in processing claims. This makes a difference in determining new and established patients, and in processing for multiple hospital visits by different specialty physicians on the same calendar day. Physicians in a group of the same specialty must bill and be paid as if they were one physician.

Specialty designation and new patients

There are several coding rules that are directly affected by this. Whether or not a patient is a new patient to the physician. Let’s start with the definition of a new patient, from Medicare and CPT®.

CMS definition (Medicare):

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

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Last revised November 23, 2021 - Betsy Nicoletti
Tags: Code sets and reimbursement

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

2023 E/M reference sheets

These handy quick reference sheets included at-a-glance MDM requirements for office, hospital, nursing home and home and residence services. And, a bonus sheet with typical time for those code sets. Sign up for Betsy’s monthly newsletter to download these reference sheets and share them with your practitioners.

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2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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