Inpatient Facility Coding & Compliance Alert

Question: Many of my coworkers seem to use the terms “health care provider” and “health care practitioner” interchangeably, but one of our supervisors says they’re not the same thing. What’s the difference?

North Carolina Subscriber

Answer: Terminology in this area is, at best, difficult. In normal parlance, the phrase “health care provider” refers to any individual or entity that provides healthcare services. When you move into the Medicare payment context, more precise terminology is needed.

CMS difference: For Medicare payment purposes, there are generally two classifications: “provider” and “supplier.” “Providers” are entities such as hospitals or skilled nursing facility that have formal provider agreements with the Medicare program. Everything else falls into the category of “supplier.” This includes physicians and practitioners along with entities such as DME suppliers. When reading Medicare laws, rules and regulations, keep this distinction in mind.

A new winkle to terminology is that CPT® is now using the phrase “qualified health care professional.” This terminology is used for clinical purposes, not necessarily payment purposes. A qualified health care professional indicates that the given individual is allowed to provide a given service.

Thus, physicians, practitioners, and nurses, among others, are all “qualified health care professionals.” There is similar phraseology in EMTALA (Emergency Medical Treatment and Labor Act) in which the medical screening examination must be performed by a practitioner or other “qualified medical person.”

Example: An RN is a qualified health care professional (and thus a health care provider) that is not a practitioner. An ARNP (Advanced Registered Nurse Practitioner) is a qualified health care professional (and thus a health care provider).

Consideration: Determining exactly what CPT® means by “reporting” services attributed to a qualified health care professional is an interesting question, particularly relative to professional coding/billing and facility coding/billing. Oftentimes, services are reported but there may be no reimbursement. Also, in a hospital outpatient setting (such as an infusion center), there are specially trained nursing staff who, under the direct supervision of a qualified practitioner, will report the services for billing on the hospital side.

A mini example of this issue is with the parenthetical guidance with 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). CPT® states in this case for hospitals, “Hospitals may report 96372 when the physician or other qualified health care professional is not present.” The Medicare program certainly disagrees with this general statement in that direct supervision is required on the hospital side to code and bill for the 96372.