Non-Physician Practitioner in Multi-specialty Group - JF Part B

Noridian recognizes the composition of provider practices has changed and it may be common to include physicians (MD or DO), nurse practitioners (NP) and physician assistants (PA). This page describes the CMS guidelines for performing and billing such services appropriately, along with Noridian's process for E/M codes 99202-99215, 99221-99233, 99238, 99239.

When multiple NPPs perform individual E/M services on the same day, for the same patient, only one of the NPP claims will be paid per day by the MAC. We recognize that NPPs are now practicing within subspecialty groups, but we remind providers that, at present, CMS does not currently assign subspecialty designations to nurse practitioners or physician assistants. Specialty type 50 (NP) and 97 (PA) will only allow one NPP service per beneficiary, per day. In addition, if a patient has been treated by a provider of the same subspecialty within a 3-year period, claims will deny.

In response to reduce provider burden in the Medicare claim process, Noridian received questions and made a significant change in submission and processing steps for E/M services performed by NPPs.

Effective March 1, 2022, E/M services submitted by NPs (Specialty 50) and PAs (Specialty 97) can be considered for coverage when another E/M service from a multispecialty group has been provided.

• More than one E/M service by PA or NP payable on the same day
  CMS allows one E/M service per beneficiary, per day, per provider specialty type. Since PAs and NPs often provide specialty care (e.g., family practice, psychiatry, orthopedics), multiple E/M services on the same DOS may be permissible, when each episode of care is addressing a different clinical condition. The additional E/M service would need to be medically necessary to treat an illness or injury separate from the initial E/M service. A different diagnosis would be required.
• Changes in processing NP and PA claims for E/M services
  As of March 1, 2022, NP and PA providers will need to include additional information on each E/M claim, defining the specialty of the physician group when care is rendered in a specialty practice environment. Claims will be suspended to review specialty information and compare diagnosis codes. When both the specialty information and diagnoses are different, the second claim may be payable.
• How do NP and PA providers include specialty information on their claims?
  When a service is rendered by a NP (Specialty 50) or PA (Specialty 97) in multi-specialty group, the subspecialty information must be included in the 2400 NTE Segment Loop on electronic claims or Box 19 of the CMS 1500 form (example: 06-cardiology). If the subspecialty information is missing on either the current or history claim, the subsequent E/M service may deny. Specialty codes and their definition that can be found on our website at Eligible Specialties.
  • Note: If practicing as an NPP in a multi-specialty group, add specialty 50 or 97 in the 2400 NTE Segment Loop on electronic claims or Box 19 of the CMS 1500 form to avoid future denials of new patient services performed under a sub-specialty.

E/M services should always accurately reflect the level of care provided during any patient encounter. CMS considers duplicative or overlapping care as medically unnecessary and MACs pay or deny such services only within the confines of CMS rules and guidelines. When multiple same-day E/M services are billed for the same beneficiary by several provider types, the following rules apply:

• When an MD and NPP from the same provider group each perform individual E/M services on the same day, for the same patient, the service should be billed as one service, using the MD's billing identifier. These combined services may support a higher level of E/M coding than either service when billed alone.
  • "Incident to" requirements as defined in CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60. The billing physician must be present in the same office suite or area during performance of an E/M visit by an NPP, to bill the service using the physician's NPI, rather than the NPPs. The "incident to" concept does not apply in the hospital or skilled nursing facility setting.

CMS editing only permits one new visit per provider specialty type within a group over a three-year period. Since NPs and PAs are two different provider designations, new visits by each within a three-year period may be payable. If the subspecialty information is missing on the original claim causing a denial, it may result in a provider submitting an appeal. However, Noridian's goal is to reduce the number of submitted appeals when the specialty and reason for the visit are different between the two E/M services. By placing the subspecialty in box 19 initially, it reduces the probability of a denial.

Example: if the patient was seen in a multi-specialty practice as a new patient by a specialty 50 working within family practice (specialty 11) and then seen within three years by a specialty 50 working within cardiology (specialty 06), the second new visit would be denied without the subspecialty information included in the comment field. If the documentation submitted with an appeal supported a medically necessary service addressing a distinctly separate problem, the second service may be payable on appeal. It is permissible to bill these services as subsequent visits, since they are considered as subsequent care by a same-specialty provider in the group. If the provider submitted both claims with the subspecialty information included in box 19, the claim would not have initially denied.