The fact that the only term used in the code language is physician does not prohibit non-physician providers from using the codes for reimbursement. CNMs should not be allowed to bill for high risk codes. CNMs should not be attending high risk patients who have complicated pregnancy problems beyond their scope of practice. High risk patients seen by CNMs are often those with psycho-social problems such as adolescents, smokers, and victims of domestic violence. High risk CPT codes are primarily based on assessment and amount of time spent with a particular patient rather than on the actual diagnosis.
Providers are aware that patients with psycho-social problems require additional time.
CNMs have been shown to be effective care providers for many of these high risk patients and should be able to bill under the high risk codes. In addition, it may take a considerable amount of assessment time to learn that a patient should be designated as high risk, and CNMs should be allowed to bill under the high risk codes for that time. If reimbursement codes exist for procedures outside a CNM s scope of practice, the CNM will see these as permission to perform procedures for which a CNM was not originally trained. It is highly unlikely that an agency charged with paying bills has the desire or capacity to monitor scope of practice. But, if third party payers are given the responsibility to police providers to make sure the actual procedure they are performing and billing for is in line with their qualifications, then all providers, including physicians, should be subject to this enforcement.