Medicare Compliance & Reimbursement

If you've wondered what "other qualified healthcare professional" means when you see it in a code descriptor, such as 90460-90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional ...). If your MAC follows CPT® rules, you can exclude registered nurses from that list.

At the request of many physicians, CPT® 2012 now defines the terminology.

Although this definition didn't make it into the 2012 manual, the AMA lists it as part of the "CPT® 2012 Errata" on its Web site (www.ama-assn.org/resources/doc/cpt/cpt-2011-corrections.pdf) and the definition is as follows:

"A 'physician or other qualified health care professional' is an individual who by education, training, licensure/regulation, and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports a 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 health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service. Other policies may also affect who may report specified services."

Here's why: Leaving RNs and LPNs out of the definition means that CPT® will now preclude RNs and LPNs from reporting certain codes that are meant for physicians and "other qualified healthcare professionals," says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. For example, you won't be able to report immunization administration codes 90460-90461 if a nurse performs the administration.

Good news: If your practices doesn't use nurses for many services, you may not have any issues with the new wording. "In our office, that definition would not affect coding," says Nina Berrier, LPN, office manager at Watershed Urology in Carlisle, Penn. "As far as the RN and LPNs go, we are only allowed to do procedures such as insert catheters, instill BCG for bladder cancer, etc. whenever the doctor is in the office. If he is not in the office, but tells me what to do, then I can go ahead and do it but we cannot charge for that."

Part B practices may be disappointed that RNs and LPNs aren't included in the definition, because it means that CPT® will now preclude RNs and LPNs from reporting certain codes that are meant for physicians and "other qualified healthcare professionals" -- for instance, immunization administration codes 90460-90461, neuropsychological testing code 96120, cognitive testing code 96125, and prolonged E/M codes 99358-99359.

If your payer does not follow CPT® rules on this issue, you may still be able to allow an RN or LPN to perform the service, depending on what your insurer states in writing. And remember that state and local laws may specifically dictate who can perform each type of service, so look to your state medical society for information on that as well.

One of the least publicized changes in the 2012 Medicare Physician Fee Schedule could be one of the costliest if it applies to you. That's the word from Marc Hartstein, deputy director of the Hospital and Ambulatory Policy Group at CMS, who spoke about the "three-day payment window" during the CPT® 2012 Annual Symposium in Chicago on Nov. 16.

What it means: If a Medicare patient has services furnished in a facility wholly owned or operated by a hospital and then gets admitted to that hospital within three days, those prior services are bundled into the patient's hospital stay. This rule has been in place since June 2010 -- however, CMS tweaked the rule effective July 1, 2012, and now it may impact you more.

Here's why: If you're in a physician practice that's owned or operated by a hospital and you treat a patient who is subsequently admitted to the hospital within the next three days, you will collect for your service at the facility rate and not at the outpatient rate. This applies to you even if your practice is not located at the same site as the hospital. As long as it's wholly owned and operated by the hospital, the three-day payment window rule will apply.

Modifier regs: If your practice is owned and operated by a hospital and you treat a patient for a related problem within three days of her hospital admission, you'll append modifier PD to your claim to let the MAC know that your service is subject to the three-day payment rule, Hartstein said.