Non-Physician Healthcare Professionals Billing Evaluation and Management
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Defines Quartz's reimbursement stance and billing expectations for E/M and other services billed by non-physician healthcare professionals; lists specialties considered nonphysician and applies to Commercial, Level Funded, and Medicare Advantage.
No material clinical or coverage changes in this revision.
Coverage and Billing Criteria for Nonphysician Services
inv-01: Nonphysician billing and reimbursement criteria
Covered when ALL of the following are met:
ALL of the following
- E/M CPT codes (98000-98016, 99091, 99202-99499) will not be reimbursed when billed by nonphysician healthcare professionals under their own individual or group tax identification number (TIN).CPT 98000-98016, 99091, 99202-99499
- Per CPT/CMS guidance, E/M services should only be reported by physicians or other qualified health care professionals: nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), and physician assistants (PA). These qualified HCPs are not considered nonphysician HCPs for the purposes of this policy.
Select the CPT/HCPCS code that accurately describes the service performed.
ALL of the following
- Quartz may conduct post-payment reviews and audits of claims billed by nonphysician HCPs.
- Providers must provide supporting documentation when requested for such reviews; failure to comply or misuse of billing may result in education, recoupment, claim denial, adjustment, or other corrective action by Quartz.
Codes and Reporting Restrictions
| 98000-98016, 99091, 99202-99499 | E/M CPT codes that Quartz will not reimburse when reported by nonphysician healthcare professionals |
| 97802-97803 | CPT codes for medical nutrition therapy by registered dietitians |
| 99500-99600, 99601-99602 | Example CPT codes for home health and home infusion services |
| G0108-G0109, G0270 | HCPCS codes for medical nutrition therapy by registered dietitians |
Billing Compliance and Post-payment Reviews
Submit documentation for post-payment reviews and audits
Quartz conducts post-payment reviews and audits to ensure policy compliance. Providers must submit supporting documentation if requested as part of claim review processes. Misuse of codes, modifiers, or exceeding service limits may result in provider education, recoupment, or other corrective action.
- Submit requested documentation promptly to support claims during post-payment review.
- Be aware that misuse of codes, modifiers, or exceeding service limits can trigger recoupment or corrective actions.
Comply with billing and submission guidelines to avoid claim actions
Follow Quartz billing and submission guidelines and use industry-standard CPT, HCPCS, and revenue codes that are fully supported by clinical documentation. Failure to comply may result in claim rejection or denial, recovery/recoupment of payments, or adjustment of reimbursement.
- Bill services using Current Procedure Terminology (CPT), HCPCS, and/or revenue codes that accurately denote the services performed.
- Ensure clinical documentation fully supports billed codes; Quartz may use claim-editing software to assess coding and billing accuracy.
- Noncompliance can lead to claim rejection/denial, payment recovery/recoupment, or reimbursement adjustments.
Definitions: Nonphysician and Qualified Healthcare Professionals
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.