Ophthalmology and Optometry Coding Alert

Non-physician practitioner performing an E/M? Modifier SA is critical now.

Reporting E/M services is fairly straightforward - you review the documentation, select the appropriate code, and report that to payers, right? Not so fast. You'll now need to append modifier SA to the E/M code if a non-physician practitioner performed the service and your patient is insured with United Healthcare.

At issue: According to United Healthcare's June 2017 Network Bulletin, the payer has a new policy for claims with dates of service on or after Sept. 1, 2017. "UnitedHealthcare will require physicians reporting evaluation and management (E/M) services on behalf of their employed Advanced Practice Health Care Professionals to report the services with a modifier to denote the services were provided in collaboration with a physician," the payer says in the Bulletin. "UnitedHealthcare will accept the modifier SA on claims for these services when provided by nurse practitioners, physician assistants, and clinical nurse specialists."

Further, the new policy indicates that the healthcare professional's NPI must be included in field 24J of the HCFA 1500 or its electronic equivalent, says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC fellow and vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

This second requirement appears to be a way for UHC to more closely track the providers who are actually treating patients. "Use of the modifier SA and documentation of the rendering care provider will assist UnitedHealthcare in maintaining accurate data with regard to the types of practitioners providing services to our member," the Bulletin says.

Policy Isn't Universal

The requirement to utilize modifier SA (Nurse practitioner rendering service in collaboration with a physician)  isn't yet universal, with some payers, such as UHC, requiring it on services like E/M codes, while other payers specifically advise practices to avoid it.

For instance: "Effective for dates of services on or after January 1, 2017, the SA modifier should not be present when billing for services that are 'incident to' professional services," the Tufts Health Plan policy says.

Payment issues: Although UHC doesn't indicate in its policy whether using modifier SA will impact payment, some payers do cut reimbursement when modifier SA is utilized. The Cigna policy, for instance, states that modifier SA will pay "85 percent of fee schedule or usual and customary/maximum reimbursable rate."

"The CPT^® and CMS modifiers are generally well-known to the billing professionals of small and/or large practices," says Catherine du Toit, CPC, CPMA, CGIC of Clean Claims Coding Consultants. "If each insurance carrier is planning to add its own set of modifiers to indicate that NPs, PAs, and other clinical staff members performed E/M services in collaboration with the physician, things could get confusing."

Therefore, it's very important to check with your individual insurers to find out their modifier SA payment policies, whether the modifier is required on any particular claim types (procedures vs. E/M services), and whether your use of the modifier will impact reimbursement.

Resource: To read the UHC Bulletin, which includes the details on the new modifier rule, visit https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/June-Interactive-Network-Bulletin-2017.pdf.