"Other qualified healthcare professional"

medicalauditor

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Hello fellow auditors and coders: I am aware of the exact definition of "other qualified healthcare professionals" by AMA in regards to billing Evaluation & Management services, but I am looking for a more detailed description or definition of who may provide Evaluation & Management services, according to CMS. I am looking for Oregon Medicaid guidelines, but a general CMS guideline will work as well.

1. Here is the link to an AAPC article that lists the types of professionals that are considered as QHP and they state that this is per CMS guidelines, but I am unable to find the CMS document that clearly states this: https://www.aapc.com/blog/28964-define-a-qualified-healthcare-professional/

2. There is a tele-medicine provider guide by the Oregon Health Authority- https://www.oregon.gov/oha/HSD/OHP/...th Plan coverage of telemedicine services.pdf that clearly states : "Evaluation and management services (for providers who can perform these services, such as physicians, physician assistants or nurse practitioners)" - per this, only physicians, PAs and NPs can provide E/M services, but this information is mentioned in their tele-medicine guide. It would be great if I can find this statement in a general guide, not just for tele-medicine. I looked & looked but just can't find it. I also read several articles from different sources that say that only physicians, PAs and NPs can provide E/M services and most of these articles state that this is per CMS guidelines, yet I can't seem to find the CMS guideline that everyone is referring to. Can someone please help?

To summarize, I am looking for a CMS and/or OHA guideline that clearly says which providers may bill E/M services (physician, PA, NP).

Thank you.
 

vinessachilders

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For guidelines from CMS, you would probably do better to check your local MAC. They will define which certifications support their "qualified health professional". The reason is some payers have differing opinions on who they term QHPs, and each payer will allow their own definition to support paying the charges. Our state Medicaid program does not recognize all the QHPs our local MAC or our local BCBS does. I think that is why there isn't a blanket list.
 
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