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Medical Coding News Archives

CPT and the ‘Other Qualified Health Care Professional’

November 8, 2012:

Kelly Canter, BA, RHIT, CCS, Manager, Clinical/Technical Editors

In the 2013 CPT update, the American Medical Association (AMA) revised many code descriptions and coding notes to clarify that codes may be used by providers other than physicians.

By using the terminology “physician or other qualified health care provider” (OQHCP), the CPT code set avoids statements identifying who is allowed to perform a service other than that he or she must be qualified. For example, prior to the 2013 update, many of the descriptions for evaluation and management (E/M) codes included the term “physician,” making assignment of those codes confusing for the nonphysician practitioners who could also report E/M services.

In the 2013 instructions for using the CPT manual, the AMA notes that the procedures and services listed throughout the book are for use by any qualified physician or other qualified health care professional or entity; for example, hospitals, laboratories, or home health agencies. The instructions go on to clarify that the phrase “physician or other qualified health care professional” (OQHCP) was adopted to identify a health care provider other than a physician. The CPT book defines this type of provider as an individual “qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable).” The qualified health care professional, who is separate from “clinical staff” and can practice independently, may report services independently or under incident-to guidelines. The CPT book defines clinical staff as “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, but who does not individually report that professional service.” Keep in mind that other policies or guidelines may also affect who may report a specific service.

The following professionals are included in OQHCP (please note this list is not all inclusive): nurse practitioner (NP), certified registered nurse anesthetist (CRNA), certified registered nurse (CRN), clinical nurse specialist (CNS), and physician assistant (PA).


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