Our claims are billed under a group National Physician Identifier (NPI). Would a referral from optometry to ophthalmology within our practice allow billing as a new patient?

Answer:
Ophthalmology and optometry are different specialties per taxonomy, and the Centers for Medicare & Medicaid Services (CMS) recognizes them as separate specialties. However, you should review each payer’s policy individually. Some commercial payer credentialing places optometry and ophthalmology in one specialty. For example, a BCBS policy states, “Optometry and ophthalmology in the same group would be considered the exact same specialty/subspecialty.” Likewise, contracts may state that they recognize the filing by taxpayer identification number (TIN) and patients are not considered new unless they have not been seen for more than three years (3 x 365 + 1 days).