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Defining Clinical Staff and Other Qualified Health Care Professionals

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Defining Clinical Staff and Other Qualified Health Care Professionals
As new policies are defined and old ones clarified, who can perform what services and where seems to be the question of the day.  The role and classification of NPs, PAs, LPNs and MAs all are in question.  Varying state scope of practice laws and regulations play a large part in the answer to the question of who is considered “clinical staff” and who is considered “other qualified health care professionals.”  Specialty designation must also be considered when looking at how a payer classifies physicians and other staff members providing care to a patient.  
We know that all physicians of the same specialty in the same group are considered as one when providing services to patients.  Many times their work is combined to achieve the level of service billed by providers under one name.  Medicare defines “other qualified health care professionals,” as listed in “Instructions for Use of the CPT Codebook,” as the following:

When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician.  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.
According to the same instructions, “clinical staff” is defined as follows:

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 specific services.  

Under this definition of clinical staff, only those who are “licensed” in the state are considered “clinical staff.”  This creates some uncertainty and varies by state for medical assistants (MAs) creating confusion for some offices.   Are MAs licensed so they are considered “clinical staff,” or are they only registered which means they are not?  This clarification is important when using the services of MAs, especially for the new Chronic-Care Management and Transitional-Care Management service codes which require that “clinical staff” perform a significant part of the service code.