Nonphysician Practitioners-Reducing Costly Appeals; Increase Provider Revenue

National Government Services is committed to reducing the provider burden associated with Medicare claim denials and appeals. A significant segment of denials and appeals for E/M services are those associated with multiple E/M services submitted by NPPs in group practices for both new patient visits and for multiple NPP visits on the same DOS.

In CY 2018, NGS implemented a process in which E/M claims by NPs and PAs can reflect the physician specialty in which the NP or PA provided the E/M service. This step allows NGS claim examiners to compare a second E/M service on the same date to the claim already paid in history. When both the physician group specialty and the diagnosis on the second claim is different from those on the history claim, the second service may be payable.

On all E/M service claims, NPPs should enter a provider specialty as either Spec. 50 (NP) or Spec. 97 (PA). In addition to that basic claim information, NPPs should enter additional information, identifying the provider specialty of the physician sub-specialty in which the service was provided. This sub-specialty information in entered on the electronic claim in the Loop 2300 NTE Segment or in Box 19 of a paper claim. For example, an NPP seeing a patient within the cardiology sub-specialty area would enter Spec. 06 in the Loop 2300, while an NPP seeing that same patient the same day in the psychiatry sub-specialty area would enter Spec. 26.

NGS offers the following on this highly recommended process.

Is more than one E/M service by a PA (Specialty 97) or NP (Specialty 50) payable on the same DOS?

Answer: CMS permits 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 in a different sub-specialty area.
What are the changes in NGS processing NP and PA claims for E/M services?

Answer: We have instructed NP and PA providers to include information on all of their E/M claims, defining the specialty of the physician group in which the care was rendered. When this information is identified on a claim, the claim suspends for examiner review; the examiner compares the information on the paid history claim with the information on the claim now pending.
How do NP and PA providers include physician specialty information on their claims?

Answer: This information is to be included in the 2300 NTE Loop Segment on electronic claims or in Box 19 on paper claims. The claims are to be submitted with either NP (Specialty 50) or PA (Specialty 97) as the rendering provider as usual, with this additional information entered separately, describing the specialty of the physician practice in which the care was rendered.
Where can a list of CMS provider specialty designations be located?

Answer: We have posted a copy of the Medicare Provider/Supplier Specialty Codes on the Enrollment > Helpful Tips section of our website.
How will NGS be processing these NP and PA E/M claims?

Answer: The first E/M claim from an NP or PA on a DOS will process as usual, however, subsequent NP and PA claims on that DOS will be suspended for review of the physician specialty group information and also a comparison of the diagnoses on the paid claim vs. any subsequent claim. When both the physician specialty information and the diagnosis code on the two claims are different, the second claim may be payable.
Please define the diagnosis requirements for these claims.

Answer: When claims for services by multiple NPs and PAs on the same DOS are received, the diagnosis on each of these claims will be compared with any other paid E/M claims on that DOS. If an E/M claim has already been paid to an NP or PA for treatment of a particular diagnosis, any subsequent claims with that same diagnosis will be denied.
In a specialty group, will two E/M claims with the same diagnosis be payable, if they are submitted by a physician and also an NP or PA in that group?

Answer: In a group practice, it is not permissible to submit two separate E/M claims for care rendered by both a physician and an NP or PA that addresses the same clinical problem. For example: an NP elicits a patient history and decides to request a physician’s participation in the care. In this scenario, care rendered by the two practitioners is combined in level-setting the visit, but only one visit is billable to Medicare.
If an NP or PA E/M claim is missing the physician group specialty information, will it still be considered for payment?

Answer: As above, the initial E/M service may be payable; subsequent same-specialty E/M services on that same DOS will be denied if the physician group specialty information is missing from either the paid history claim or the claim now pending. This denial may be appealed via the standard appeal process.
Do all NPs and PAs have to comply with these new billing instructions?

Answer: This is a voluntary but highly recommended process, designed to decrease the administrative burden associated with these claims. NGS encourages all NPs and PAs to initiate this change as soon as possible.
How does this change impact independent NP groups?

Answer: This will not permit multiple E/M services within the NP group on the same DOS (since the NP specialty will be the same) but will permit comparison with another NP service on that date, performed within a different specialty group environment and addressing a different clinical condition.
If a NP or PA E/M service is denied, what are the options for appeal?

Answer: Denied NP or PA E/M services are still subject to the standard appeal process.
In a group practice, can more than one new patient visit be paid to a physician, NP, or PA provider within a three-year period? Does this apply to situations when both a physician member and an NP or PA member submit a claim for a new patient visit within a three-year period?

Answer: A patient is considered new to a same-specialty group only once within a three-year period. In a multi-specialty group, a second new visit may be payable when the specialties on the history and pending claims are different. This rule also applies to new visits by NPs and PAs in a group, but only when there is information (as described above) on both claims that allows NGS to apply this ‘different specialty’ rule to the pending claim. When this information is missing on either the paid or pending claim, the second service will be denied and the denial may be appealed.
Please define the reason code that is associated with denials for multiple NP or PA services on the same DOS is N20.

Answer: The reason code that is associated with denials for multiple NP or PA services on the same DOS is N20.
Please define the reason code that is associated with denials for multiple NP or PA new patient services within a three-year period.

Answer: The reason code associated with denials for more than one new patient visit in a three-year period is M13.

Nonphysician Practitioners-Reducing Costly Appeals; Increase Provider Revenue

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