Found the references for 2 MACs
Noridian
https://med.noridianmedicare.com/we...ysician-practitioner-in-multi-specialty-group
"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."
My MAC also allows new patient NPP based on the specialty of the supervising physician but specifies this ONLY applies to NGS and to consult the appropriate MAC if not NGS. Honestly, I thought this was CMS guidance and not MAC specific, but it might be.
https://www.ngsmedicare.com/documen...7-6c90-5794-9f2b-eb5e7f5c4abd?t=1668509782720
So, if you submitted the 99205 by the APRN correctly, who was the supervising provider and what is their Medicare 2 digit specialty code?
If this is not a Medicare patient, most commercial plans use taxonomy codes instead of CMS specialty codes to determine new/established.
If the MD is the same specialty as the supervising provider on 99205, this is established.