General Surgery Coding Alert

Don't limit E/M services to general surgeons in your practice.

If you've been losing pay when a physician assistant (PA) or other appropriate caregiver performs E/M services in your surgical practice, recent changes could come to your rescue.

You'll find revisions to more than 80 E/M codes in CPT® 2013 that allow you to bill services for certain "qualified healthcare professionals" other than physicians. We'll show you what you need to know now to take advantage of the change.

Get Familiar With Code Modifications

Throughout the revised code definitions, CPT® 2013 makes certain additions and deletions to clarify who can bill for the E/M service.

For example: The explanation with many E/M codes for settings from office to hospital now read, "Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. ... Typically, XX minutes are spent face-to-face with the patient and/or family."

Differences: Previous descriptors stated that the counseling and/or coordination of care took place with "other providers or agencies." The face-to-face time associated with each code also was attributed to the physician instead of being open to physicians or other qualified providers.

Look to Table 1 to see a list of revised CPT® 2013 codes that will include "other qualified healthcare professionals."

Know the 'Qualified Healthcare Professional' Definition

Although you won't see code-definition changes until 2013, the AMA actually released the definition of "other qualified healthcare professionals" in CPT® 2012 errata, 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 that the AMA received related to immunization administration codes that used the terminology (e.g., 90460-90461, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional ...). The definition helps to "clarify healthcare professionals as distinct from clinical staff," according to a 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.

Tip: PAs (with various certification designations such as PA-C) and Advanced Registered Nurse Practitioners (ARNP) qualify as "other qualified healthcare professional," in most cases.