Can anyone explain the diffinition of "other qualified health care professional" in the verbiage of CPT codes 90460 and 90461? We have always considered the nurse as a qualified health care professional. Thank you ~~
A healthcare professional is qualified to do any procedure within their scope of practice. For example, a registered nurse and a Licensed practical nurse are both allowed to start IV's but a Licensed practical nurse is not allowed to give IV push pain medication. Another example, a physician and a nurse are allowed to give sq and IM injections but a nurse is not allowed to give epidural injections. So, if the healthcare professional performed procedure 90460, and that procedure is within his/her scope of pratice, then it can be billed or otherwise it becomes a disciplinary action. One more example, a nurse can make a nursing diagnosis which would be symptoms, but cannot make a medical diagnosis.
CPT 2012, Professional Edition now includes an expanded definition on page X of the introduction.
"A 'physician or othe qualified healthcare professional' is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privilege (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 healthcare 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 specific services."
There's a lot of "what ifs" in that definition.
Does that mean that those providers who are able to independently perform and bill (report?) a professional service are considered "qualified healthcare professionals"? But what about NPs and PAs who work under incident-to guidelines? Are they not "qualified healthcare professionals" because they do not independently report their services?
My opinion is that because the AMA is not a legislative body, individual state scope of practice laws/regulations trump the AMA/CPT definition of a qualified healthcare professional. I could be wrong.
When a NP or PA perform services within their scope of practice, in certain circumstances depending on location and the state laws, they may directly bill Medicare with their own provider number, they may or may not get 100% reimbursement. Also, when the CPT description states, "or other qualified healthcare professional", the facility or physician will bill the services of the NP or PA with a HCPCS modifier -AS or modifier -80 for their assistance at surgery. As long as the healthcare provider performs procedures within their scope of practice depending on what state they practice, they will be considered,"other qualified healthcare professional" no matter how the procedure is billed as long as they are qualified to perform those procedures.
For example: A PA or a NP can bill for diagnostic Psychological and Neuropsychological tests to the extent authorized under State scope of practice because diagnostic tests need not meet the "incident to" requirements. Diagnostic tests may be furnished under situations that meet the "incident to" requirements but this is not required. However, carriers must not scrutinize claims for diagnostic tests utilizing the "incident to" requirements.