How Does CPT Define a Clinical Staff Member?

 

Current Procedural Terminology (CPT) code 99490 requires patients spend 20 minutes of non face-to-face time a month with clinical staff or a physician. Throughout CPT physician, individual, and other qualified healthcare professional are used interchangeably. Clinical staff are classified differently than these professionals.

CPT Definition for Clinical Staff

Clinical staff is defined as those working under the supervision of a physician or other qualified healthcare professional (QHP). These individuals must still work within their scope of practice and local state regulation.

Clinical staff can include:

  • nurse practitioners
  • physicians assistants
  • clinical nurse specialist
  • certified nurse midwife

AMA 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.”

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Qualified Health Care Professional (QHP)

In 2013 the American Medical Association (AMA) revised many code descriptions so they could be used by providers other than physicians. The CPT book defines an individual as “qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable).” Any time spent by the QHP also can count towards the 20 minute monthly minimum to bill for CTP 99490. Time spent supervising does not count towards the minimum they must be performing specific CCM activities.

To bill to the 99490 code the staff must still meet Medicare’s “incident to” rule. This means they must meet the rules for supervision by QHP, scope of practice, and state regulations/laws. Other staff members that are not QHP or clinical staff can help administer chronic care management but there time is not counted towards the monthly minimum of 20 minutes.

Implications on Chronic Care Management

To bill for chronic care management patients must get at least 20 minutes of clinical staff time directed by a QHP. The staff can break this time up over multiple interactions to total 20 minutes. If two providers are delivering services at the same time only one of the provider’s time can be counted towards the 20 minutes. Since patients must have access to a clinical staff member 24/7 the QHP does not need to be present in the office at the time the services are rendered.

Clinical Staff EHR requirements

Clinical staff must electronically capture their care plan information in an electronic health records (EHR) system. The patient's care plan must be accessible from the EHR. Clinical staff need to update the summary of care record for each patient.

Does the clinical staff have to be a direct employees?

To bill for chronic care management the clinical staff does not need to be a direct employee of the practitioner. This allows a third party provider to help deliver chronic care management services. In this arrangement the third party provides 24/7 online and phone access for patients. This is one of the many requirements to bill for chronic care management code 99390.

Future changes to definition

Each year in October the Current Procedural Terminology (CPT) is updated by the American Medical Association. The codes are used communicate information for stakeholders in the healthcare system. This includes doctors, patients, administration, and other groups. Each year the CPT codes are updated in October. It is possible that these definitions and interpretations could change. Make sure to check the most recent CPT definition each year.

Conclusion

Clinical staff’s time can bill to chronic care management plans under the supervision of a qualified healthcare professional (QHP). Clinical staff can not bill for chronic care management without the indirect supervision of a QHP. By utilizing clinical staff you can setup chronic care management plans for your patients without adding a large time requirement for your physicians.

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