Wiki RN Counseling Contribution to Physician E&M Coding

[coding@pprm.org]

I am seeking your expertise regarding a specific question within medical billing and coding for which we have not found a definitive answer. The question pertains to Registered Nurses (RNs). Specifically, do their counseling sessions contribute to the calculation or justification of the Physician's Evaluation and Management (E&M) code?

We understand that RN counseling contributes to the patient's overall care. However, if a physician bills for an E&M code where an RN exclusively conducted the counseling—for example, regarding birth control options—can the physician still bill for that E&M code based on the RN's documented counseling? We need clarification on whether RNs qualify as Qualified Healthcare Professionals (QHPs) according to AMA/CMS guidelines in this context.

Your insights on this matter would be greatly appreciated. Thank you!

 

[jkyles]

Hi, a registered nurse is clinical staff, not a QHP. If the encounter meets the requirements for an incident-to service you could report the appropriate code. Remember that clinical staff time can't count toward E/M time for level-based codes.

See p. 5 of the 2026 CPT manual for the definition of clinical staff and the difference between physician/QHPs and clinical staff.

 

[coding@pprm.org]

I appreciate your response. Since the clinical staff can't count towards E/M time, can it counts towards the physician's E/M billed by MDM and not time?

 

[jkyles]

That would depend on whether the physician uses that counseling for their medical decision making for that visit. If the counseling just happens to occur on the same day as an E/M visit it would not.