Pain Management Coding Alert

Reader Question:

UHC Adds Modifier Requirement for these E/Ms

Question: Our practice has been told that there are new rules for nurse practitioners (NPs) performing evaluation and management (E/M) visits for patients insured by UHC. What changes have been implemented?

Iowa Subscriber

Answer: For any UnitedHealthcare (UHC) patient with an E/M service rendered by an NP, physician's assistant (PA), or clinical nurse specialist (CNS) on or after Sept. 1, 2017, you will be required to append modifier SA (Nurse Practitioner rendering service in collaboration with a physician).

To further elaborate on the modifier description, the SA modifier is defined as such:

  • "A supervising physician should use this modifier when billing on behalf of a PA, ANP, or CRNFA for nonsurgical services. (Modifier SA is used when the PA, ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery.)"

According to a UHC announcement, "Effective 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. UnitedHealthcare will accept the modifier SA on claims for these services when provided by nurse practitioners, physician assistants and clinical nurse specialists."

In other words, this modifier tells the payer that the E/M services rendered by the advanced-practice provider (APP) were performed in conjunction with the provider. Providers will simply use this modifier as a means of differentiating between E/M services the provider directly performs versus those an APP performs under provider supervision.

UHC goes on to explain: "In addition, the rendering care provider's National Provider Identifier (NPI) must also be documented in field 24J on the CMS-1500 claim form or its electronic equivalent. 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 members."

Keep in mind: Medicare does not recognize the SA modifier, but other payers might. If you are unsure of whether to apply modifier SA, contact the payer to confirm.