Cardiology Coding Alert

The impact on 90460-90461 has some practices unhappy.

At the request of many physicians, CPT® 2012 now defines the term "other qualified healthcare professional."

Although this definition didn't make it into the 2012 manual, the AMA lists it as part of the "CPT® 2012 Errata" on its website (www.ama-assn.org/resources/doc/cpt/cpt-corrections.pdf). The definition is as follows:

"A 'physician or other qualified health care professional' is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

"These professionals are distinct from 'clinical staff.' A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service. Other policies may also affect who may report specified services."

The definition was in "response to questions at 2011 Symposium related to 90460-90461 counseling requirements" and helps to "clarify healthcare professionals as distinct from clinical staff," according to the E/M and Vaccines presentation by Peter A. Hollmann, MD, AMA CPT® Editorial Panel Chair, at the CPT® and RBRVS 2012 Annual Symposium.

Result: "RNs and LPNs aren't included in the definition because they cannot independently report the professional services that they provide," explains Kent J. Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. RNs and LPNs fit the CPT® definition of "clinical staff," since their professional services are typically reported under a physician or other qualified health care professional's identification number (e.g., under Medicare's "incident to" rule). "This means that when certain CPT® codes refer to 'other qualified health care professionals' they are excluding RNs and LPNs," Moore says.

Example: Immunization administration codes 90460-90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional ...) refer to "counseling by physician or other qualified health care professional." Thus, counseling by an RN or LPN would not qualify to meet the requirements of these codes. Other examples include prolonged service E/M codes 99358-99359.

Bright side: An ARNP (Advanced Registered Nurse Practitioner) should qualify as a "qualified healthcare professional." Additionally, if your payer does not follow CPT® rules on this issue, you may still be able to allow an RN or LPN to perform the service that CPT® restricts to "other qualified health professionals," depending on what your insurer states in writing. Your practice should always review the state and local laws created to outline what different providers can perform based on their scope of practice. The information may be located on your state medical society website.