Oncology & Hematology Coding Alert

For accurate claims, distinguish these professionals from 'clinical staff.'

The definition of "other qualified health care professional" didn't make it into the CPT® 2012 manual, but you need to know and apply this definition all the same.

The AMA lists the definition 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."

Understand Practical Application of the Definition

The definition was in "response to questions at 2011 Symposium related to 90460-90461 [Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional ...] 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.

Key: "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 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.

More information: Be aware this concept is not new. Shortly after the effective date of the 90460 and 90461 codes, CPT® Assistant (March 2011) clarified the "other qualified health care professional" concept. Because 90460-90461 replaced 90465-90468 (Immunization administration younger than 8 years ... when the physician counsels the patient/family ...), which by definition required face-to-face counseling by a physician, the "other qualified healthcare professional" in 90460-90461 was intended to be a billing provider such as a PA or NP.

The CPT® Assistant article states: "The addition of 'qualified health care professional' reflects the recognition that often registered nurse practitioners and physician assistants perform and report these services, but it should not be interpreted to mean that other types of office clinical staff may provide the counseling. While an office nurse may be allowed by applicable statute or regulation to explain risks and benefits of vaccines to a parent or guardian, that process does not allow the reporting of codes 90460 and 90461, but rather is included in services described by codes 90471-90474 [Immunization administration ...]."

Ensure the counseling service is appropriately rendered and documented when reporting 90460-90461. The "other qualified health care professional" definition should also be considered for other CPT® codes that include "other qualified health care professional" in their code definitions.