BUSINESS

  CODING STRATEGY

UNDERSTAND LOCUM TENENS

USE Q MODIFIERS FOR TEMPORARY PHYSICIAN SERVICES

IT IS not unusual for a physician to fill in for a doctor who is on vacation or ill. It is also common for a physician to work in more than one practice by combining a couple of part-time jobs. Unfortunately, many physicians are not aware of how to accurately submit claims for these situations.

One of the major issues to avoid: An O.D. cannot see patients on an ongoing basis under another’s National Provider Identification (NPI) if you are not credentialed and the other optometrist is in the office simultaneously.

Fortunately, the concept of Locum Tenens allows for fill-in doctors and mitigates the risks. The applications of the rules described here apply to Medicare patients; check with individual carriers for unique application.

APPLYING THE CODES

A fill-in doctor can see the patients of a regular practitioner through the appropriate use of the Q5 or Q6 modifiers.

Q5 indicates a reciprocal billing arrangement. The patient’s regular physician may submit the claim, and (if assignment is accepted) receive the payment, for covered visit services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:

• The regular physician is unavailable to provide the visit services;

• The patient arranges or seeks to receive services from the regular physician;

• The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days; and

• The regular physician identifies the services as substitute physician services by entering in the appropriate CPT code with the -Q5 modifier after each specific procedure code.

Inappropriate usage:

• When the physician is covering for an absence longer than 60 days

• When the physician is in the same group and same specialty

Q6 indicates a Locum Tenens arrangement. Practices usually use locum tenens physicians when the regular physician has left the practice or is absent because of vacation, illness, childbirth, business, education or active duty military service. A patient’s regular physician may submit the claim, and receive payment, for covered visit services (including emergency visits and related services) of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices, if:

• The regular physician is unavailable to provide the visit services;

• The Medicare beneficiary arranges or seeks services from the regular physician;

• The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis;

• The substitute physician does not provide the visit services to Medicare patients over a 60-day continuous period, subject to the exception noted below; and

• The regular physician identifies the services as substitute physician services by entering in the appropriate CPT code with the –Q6 modifier after each specific procedure code.

Inappropriate usage:

• When the physician is covering for an absence of longer than 60 days

• When the physician is in the same group

ABIDING BY THE RULE

The advantages of properly using these modifiers are that it:

• Retains the regular physician’s existing patients

• Introduces new patients to the practice

• Maintains the patient level

• Keeps revenue with the regular physician

The period a temporary doctor may substitute for the regular physician cannot be more than 60 continuous (not work) days. This 60-day period begins the first day the temporary doctor provides services. There are obligations and responsibilities for both parties during this time.

The regular doctor:

• Must schedule appointments under his or her schedule.

• Is the only physician who can break the 60-day period.

• May reset the 60-day period by returning to practice and see patients as soon as one day after the initial 60 days and use the same temporary doctor.

• Must bill for the services of the temporary doctor.

• Must put his or her NPI number on all filed claims.

• May use more than one temporary doctor to substitute for absences during the 60-day period.

• May reimburse the temporary doctor a fixed amount per diem or similar fee for time.

• Must keep a record of each service furnished by the temporary doctor physician and the NPI.

The temporary doctor:

• Fills in for the regular physician for no more than 60 continuous calendar days.

• Can substitute only if the regular physician is absent for any of the reasons above.

• Cannot substitute more than 60 continuous calendar days, unless there is a break in the 60-day by the regular physician.

• Cannot reset the 60-day clock by taking a day off.

• Generally does not have a practice of his or her own and moves from area to area as needed.

• Is usually an independent contractor of the regular physician or group rather than an employee.

• Does not have to be enrolled in the Medicare program to see Medicare patients

• Cannot bill Medicare for services within the 60-day continuous period in his or her name or NPI.

TIME FOR VACATION

Be aware of the implications of providing services for another doctor under their NPI. Following these rules (specific for each carrier) will allow seamless coverage for patients without creating a potentially hazardous situation for any providers involved. OM

JOHN RUMPAKIS, O.D., M.B.A., is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com, or visit tinyurl.com/OMcomment to comment on this article.