by Wyn Staheli
March 4th, 2016
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.
- 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.
- Definition of 'education and training' differences can exist on not only the state and federal level, but also at a third party payer level.
- 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.