Urology Coding Alert

Watch out: The new definition isn't all good news.

If you've wondered what "other qualified healthcare professional" means when you see this phrase in a particular code or modifier description, such as for modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperativ period), CPT® 2012 has the answer.

At the request of many physicians, CPT® 2012 now defines this terminology. Here's what you need to know.

Don't Miss Errata Clarifications

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) with the definition 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."

Important: Checking the AMA errata for such corrections is very important, says Denae M. Merrill, CPC, HCC coding specialist in Holland, Mich.

Beware What the Definition Doesn't Include

You may be disappointed that RNs and LPNs aren't included in the definition.

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 only 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 bill a surgical correction of a postoperative complication in the global period with modifier 78 if a nurse performs the service.

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."