What is an Other Qualified Healthcare Professional?

To begin to answer this question, let's review the exact wording in the CPT codebook:

“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.” - CPT Coding Guidelines, Instructions for Use of the CPT Codebook.

So according to this statement, an 'other qualified health care professional' is an individual who may legally perform that service based on scope of practice regulations. Sounds simple enough, but there are some additional factors to consider. 

  1. Scope of practice is determined at both the state and national level. As such, each state could potentially have a different list of services that a licensed professional may provide. For example, some states allow psychologists to prescribe medication and others do not.

  2. Definition of 'education and training' differences can exist on not only the state and federal level, but also at a third party payer level.

  3. Exceptions like health professional shortage areas (HPSA) may alter the definition of scope of practice in order to meet a specific need. For example, when there is a shortage of physicians in an area (HPSA), Medicare will allow other types of providers to render services that normally only provided by a physician.

Therefore, if there is a concern or question about whether or not you are a 'qualified healthcare provider' is probably best answered by communicating with both your state professional organization as well as the payer for which you wish to submit a claim for reimbursement.

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Author: 
Wyn Staheli, Director