For Service Type Codes (STC) used in the EQ01 and EB03 fields, does the term "Physician" in the definitions literally mean only a provider licensed as a Medical Doctor or is the intent more expansive to cover lower credentials such as Physician Assistants (PA) and Nurse Practitioners (NP)? The word "Physician" appears in the definition for the following codes: 96, 97, 98, 99, A0, A1, A2, A3, BY, BZ, CC.
Provider organizations are increasingly using lower credentialed practitioners to deliver primary care services, and this has led to some confusion about appropriate selection of STCs. In the medical community, allied health professionals such as PAs and NPs are generally not considered to be physicians. While those allied health professionals must work under physician supervision, they have their own NPIs and may use those when checking eligibility or submitting claims to payers.
STCs 96, 97, 98, 99, A0, A1, A2, A3, BY, BZ, and CC were originally designed with the word “physician” in the code value description purposefully to make them distinct from the word “hospital” in STCs such as 47, 48, 49, 50, 51, 52, and 53. There is no intent to limit the definition to purely physician-based usability. However, the interpretation of the values on either the request or the response would heavily depend on the parties exchanging the information as to whether or not the code values could expand to physician assistants and nurse practitioners.
It may be beneficial to identify the extensibility of the above-named service type codes in the payers’ companion guide to ensure transparency and consistent use of the service types. If needed and supported by parties involved in the exchange, the use of the PRV and a taxonomy may be of value to further clarify and distinguish between the role of a medical doctor, a physician’s assistant, and a nurse practitioner in the services being requested or returned to curb the possibility for a misquote of benefits or service eligibility, and/or increase the chances the provider may resort to a phone call.
Also, an external service type code list will be used in future versions of the 270/271 (https://x12.org/codes/service-type-codes), where many of the above-mentioned codes were modified or removed; additionally, a code description was added to BY and BZ to include “physician or other healthcare provider.” This should help those in the current situation to evaluate how they want to approach the existing code values for their own business needs. Also, the future versions of the 270/271 will accommodate tailoring more specifically to the provider submitted on the 270 to help minimize confusion with extraneous information being returned.