Physician specialty codes and claims processing

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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