EM Coding Alert

Not all payers follow this particular policy, so double-check with your individual payers.

Do you bill non-physician practitioners' (NPPs) evaluation and management (E/M) services to UnitedHealthcare (UHC)? If so, make sure you didn't miss their new policy, which now requires you to append modifier SA (Nurse practitioner rendering service in collaboration with a physician) on physician-submitted claims involving NPPs.

This policy went into effect for claims with dates of service on or after September 1, 2017, according to the Network Bulletin UHC released this summer.

"UnitedHealthcare will require physicians reporting E/M services on behalf of their employed Advanced Practice Health Care Professionals to report the serviceswith a modifier to denote the services were provided in collaboration with a physician," the payer says in the Bulletin.

UHC will accept modifier SA on claims for E/M services when nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) provide them, adds the Bulletin.

Also, the new policy indicates that the healthcare professional's national provider identifier (NPI) must be included in field 24J of the HCFA 1500 or its electronic equivalent, according to Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC fellow and vice president at Stark Coding & Consulting, LLC, in Shrewsbury, New Jersey.

This requirement seems like a method 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 members," according to the Bulletin.

The New UHC Policy Not Universal

Don't miss: This requirement to append modifier SA isn't yet universal. Some payers, like UHC, require the modifier on services like E/M codes. However, other payers specifically advise practices to avoid it.

For example:  Take a look at the Tufts Health Plan policy for clarity. "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 policy emphasizes. However, keep in mind that the "incident to" concept does not apply in facility settings like the emergency department (ED).

Payment issues: Although UHC doesn't indicate in its policy whether using modifier SA will impact payment, some payers actually do cut reimbursement when modifier SA is appended. Additionally, the policy does not clearly indicate if it should be added on claims that are reported under the NPs, PAs, or CNSs.

Cigna's policy, for example, 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."

The bottom line: It's vital to check with your individual payers to find out their modifier SA payment policies, whether the modifier is required on any particular claim types (procedures versus E/M services), and whether your use of the modifier will impact your reimbursement.