CurrentOptumPolicy N/A

Reimbursement for Evaluation and Management (E/M) services reported by nonphysician health care professionals

This policy governs Optum reimbursement for E/M services (CPT codes 98000-98016, 99202-99499) reported by nonphysician health care professionals for commercial, Medicare, and individual exchange plans and applies to claims submitted on CMS 1500 and electronic formats.

Policy Summary

PayerOptum

PolicyReimbursement for Evaluation and Management (E/M) services reported by nonphysician health care professionals

Policy CodePolicy N/A

Change TypeAdded E/M CPT range and provider type

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill E/M CPT codes 98000-98016 or 99202-99499 under a nonphysician provider's own TIN; only qualified professionals (NP, CNS, Psychiatrist, PA) may report these E/M services per CMS guidance.

SourceLink

POLICY UPDATE CHANGES

Added CPT codes 98000-98016 to the scope of E/M services referenced by the policy.

Added additional provider type MHC.

98000-98016, 99202-99499E/M code ranges addressed

Commercial/Medicare/ExchangePlan types

CMS1500 / 837p/837iClaim formats

~50+Provider types enumerated

Coverage criteria for E/M services reported by nonphysician health care professionals

E/M reimbursement criteria

Covered when meeting the following policy provisions:

E/M services (CPT 98000-98016, 99202-99499) are not reimbursed when billed by nonphysician health care professionals under their own individual or group TIN.

Qualified health care professionals who may report E/M services per CPT and CMS guidance include nurse practitioners (NP), clinical nurse specialists (CNS), psychiatrists, and physician assistants (PA).

Licensed Professional Counselors (LPC), Licensed Clinical Social Workers (LCSW), Licensed Mental Health Counselors (LMHC), Licensed Marriage and Family Therapists (LMFT), Mental Health Counselors (MHC), and Clinical Psychologists (CP) should not report E/M codes (99202-99499) because they are nonphysician health care professionals under this policy.

Policy applies to services billed on CMS 1500 forms and electronic claim submissions (837p/837i) across commercial, Medicare and individual exchange plans.

Policy Summary

PayerOptum

PolicyReimbursement for Evaluation and Management (E/M) services reported by nonphysician health care professionals

Policy CodePolicy N/A

Change TypeAdded E/M CPT range and provider type

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Codes and qualified reporters

E/M code rangesCPTNot Covered

98000-98016	E/M codes referenced for nonphysician reporting
99202-99499	E/M codes referenced for nonphysician reporting

Qualified professionals allowed to report E/M

Qualified professionals allowed to report E/MNurse practitioners (NP), clinical nurse specialists (CNS), psychiatrists, and physician assistants (PA) — per CPT and CMS guidance these are the only qualified health care professionals who may report E/M services.

Source guidanceCPT guidance and CMS guidance referenced in policy state E/M (CPT 98000-98016, 99202-99499) should only be reported by physicians or other qualified health care professionals.

Policy reimbursement implicationOptum will not reimburse E/M services when reported by nonphysician health care professionals under their own individual or group TIN.

Provider billing and reimbursement actions

Denial Risk

Denial risk — E/M billed by nonphysician providers

Optum will not reimburse Evaluation and Management (E/M) services when those services (CPT codes 98000-98016, 99202-99499) are reported by nonphysician health care professionals under their own individual or group tax identification number (TIN).

Applies to claims submitted on CMS 1500 and electronic formats (837p/837i).
Qualified reporters per CMS guidance (NP, CNS, Psychiatrist, PA) are not considered nonphysician for this policy.
Nonphysician specialties listed in the policy (e.g., LPC, LCSW, LMHC, LMFT, MHC, CP, and others) should not report E/M codes 99202-99499 under their own TIN.

Key definitions used in this policy

Physician (definition)

DefinitionA Doctor of Medicine (MD) or Doctor of Osteopathy (DO)

Role in policyConsidered a physician for purposes of this reimbursement policy; physicians and the listed qualified nonphysician professionals may report E/M codes per guidance.

ContextReferenced in the policy definitions section under 'Physician'.

Nonphysician health care professionals

Examples of nonphysician specialtiesLicensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), Licensed Marriage & Family Therapist (LMFT), Mental Health Counselor (MHC), Clinical Psychologist (CP)

Policy stanceThese provider specialties are considered nonphysician health care professionals and should not report E/M codes (99202-99499) under their own TIN for reimbursement by Optum.

Coding noteThere are many CPT/HCPCS codes that accurately describe services performed by nonphysician health care professionals; policy lists numerous provider types that are not physicians.