Healthcare Fraud Shield’s Latest Article: AMA adds “Other Qualified Health Care Professionals” to 2013 descriptions

8 Jan

AMA adds “Other Qualified Health Care Professionals” to 2013 descriptions 

The 2013 CPT® book is full of new codes, revised codes and deleted codes.    Furthermore, in the 2013 CPT® book the AMA created a marked distinction regarding the type of person or entity who can perform certain services.      The words “other qualified health care professional” were added to many CPT® descriptors, most notably in the Evaluation and Management section and Appendix A (modifiers).  More specifically, 82 Evaluation and Management codes were revised to include this language.  According the CPT® 2013 book, “a physician or other qualified health care professional” is an “individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”

For instance, in 2012, CPT® code 36410 was used for a venipuncture for someone 3 years of age or older requiring a physician’s skill.  In 2013, the code descriptor now states “necessitating the skill of a physician or other qualified health care professional.”  The effect of this change will depend upon our respective plan policies and any applicable federal and state laws (particularly those involving scope of practice guidelines). While the above description states other qualified health care professional, some states may explicitly restrict certain specialties from performing venipuncture.  One example is the State of Washington, where it defines the scope of practice for chiropractors and declares “Chiropractic care shall not include the prescription or dispensing of any medicine or drug, the practice of obstetrics or surgery, the use of X-rays or any other form of radiation for therapeutic purposes, colonic irrigation, or any form of venipuncture.” [1]

Another example is CPT® code 01991 which also now includes the terminology “other qualified health care professional.”  This code is used to designate anesthesia for diagnostic or therapeutic nerve blocks and injections; other than the prone position.    Missouri statutes contain specific restrictions pertaining to anesthesia and Physician Assistants stating “Physician assistants shall not prescribe nor dispense any drug, medicine, device or therapy unless pursuant to a physician supervision agreement in accordance with the law, nor prescribe lenses, prisms or contact lenses for the aid, relief or correction of vision or the measurement of visual power or visual efficiency of the human eye, nor administer or monitor general or regional block anesthesia during diagnostic tests, surgery or obstetric procedures.” [2]

As a reminder, refer to any relevant plan policies, federal and/or state laws. Carefully review who is actually rendering the services by not just by just looking at Box 31 on the CMS-1500 claim form, but you may need to verify by reviewing medical records or by calling patients or providers.

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[1] Washington Statute

[2] Missouri Statute 334.735

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