Provider Requirement: 90460-90461 Show Significance of 'Qualified Health Care Professional' Definition

For accurate claims, distinguish these professionals from 'clinical staff.'

The definition of "other qualified health care professional" didn't make it into the CPT 2012 manual, but you are required to know and apply this definition all the same. Read this expert medical coding insight to learn more.

The AMA lists the definition as part of the "CPT 2012 Errata" on its website. The definition is as follows: (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. 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, but who does not individually report that professional service. Other policies may also affect who may report specified services.)

Understand Practical Application of the Definition

The definition was in answer to questions at 2011 Symposium related to CPT codes 90460-90461 [Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …] counseling requirements and helps to clarify healthcare professionals as different from clinical staff.

Key: RNs and LPNs aren't included in the definition as they cannot individually report the professional services that they provide. RNs and LPNs fit the CPT® definition of "clinical staff," as their professional services are typically reported under a physician or other qualified health care professional's identification number (e.g., under Medicare's "incident to" rule). This implies that when certain CPT codes refer to 'other qualified health care professionals' they are not including RNs and LPNs.

Example: Immunization administration CPT codes 90460-90461 denote "counseling by physician or other qualified health care professional." Consequently, counseling by an RN or LPN would not qualify to meet the requirements of these codes.

More information: Understand that this concept is not new. Shortly after the effective date of the 90460 and 90461 CPT codes, CPT® Assistant (March 2011) explained the "other qualified health care professional" concept. As 90460-90461 replaced 90465-90468 (Immunization administration younger than 8 years … when the physician counsels the patient/family …), which by definition needed face-to-face counseling by a physician, the "other qualified healthcare professional" in 90460-90461 was intended to be a billing provider for example a PA or NP.

The CPT Assistant article mentions that the addition of 'qualified health care professional' echoes the recognition that frequently registered nurse practitioners and physician assistants carry out and report these services, however it should not be taken to mean that other types of office clinical staff may deliver the counseling.