APPEALS: We are a large group with many physicians and nonphysician practitioners. When we submit claims for nonphysician practitioners working in different sub-specialties, we get claim denials that state: “D463: New patient qualifications were not met or M13: Only one initial visit is covered per specialty per medical group.” How can we avoid these?

In addition to basic claim information, NPPs (specialty as Spec. 50 [NP] or Spec. 97 [PA]) should enter additional information, identifying the provider sub-specialty in which the service was provided. This sub-specialty information is entered on the electronic claim in the Loop 2300/2400 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 2300/2400, while an NPP seeing that same patient the same day in the psychiatry sub-specialty area would enter Spec. 26.