Cardiology Coding Alert

Cardiologists may be unable to see patients for several reasons, including vacation, illness and pregnancy. In such cases, many physicians, particularly those in solo practices, hire substitute physicians, commonly known as locum tenens physicians, or simply locums.

A locum does not have a practice of his or her own, moving instead from practice to practice. The cardiologist pays the locum a fixed per-diem amount as an independent contractor and bills for the service as though it were personally provided.

Many physicians confuse locum tenens billing scenarios with reciprocal billing. There are, however, two main differences, according to guidelines in section 3060.7 of the Medicare Carriers Manual (MCM):

1. Locum tenens are paid on a per-diem rate. In a reciprocal arrangement, each physician continues to bill all services to his or her own patients.

2. Locum tenens arrangements are identified by appending HCPCS modifier -Q6 (Service furnished by a locum tenens physician), whereas the reciprocal billing arrangement is indicated with modifier -Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement).

Note: Reciprocal billing guidelines are in section 3060.6 (immediately preceding locum tenens) of the MCM.

Section 3060.7 contains additional locum tenens guidelines. Cardiologists who retain locums can obtain payment from Medicare for covered services if:

The regular physician is unavailable to provide the visit services.

The Medicare beneficiary has arranged or seeks to receive services from the regular physician.

The locum is an independent contractor, not an employee of the practice, and is paid for 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 continuous period of longer than 60 days.

Any postoperative services provided by the cardiologist in a global period after the patient has had surgery should not be identified on the claim as substitution services, notes Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "You should use modifier -55 (Postoperative management only) with the appropriate procedure code for the post-op care during the global period if the surgeon performs intraoperative care only," Callaway says. The surgeon who performed the procedure should be contacted to ensure modifier -54 (Surgical care only) was appended for the intraoperative portion.

In a locum tenens arrangement, two physicians operate under the same name (not just the same practice ID number). As a result, some unusual coding scenarios may arise.

Although some coding specialists have advised that locum tenens arrangements do not apply if the physician being replaced is not returning to the practice, MCM guidelines do not agree, stating that "the physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may still be considered a member of the group until a permanent replacement is obtained."

In other words, all billing for the locum tenens is made in the name of the cardiologist who left the practice, but who, in the eyes of Medicare, remains a member of practice A until the locum arrangement ends.

The cardiologist who left practice A for practice B continues to bill under his or her own UPIN but under a different tax number, which allows carriers to distinguish between the claims. In addition, the locums claims should be appended with modifier -Q6.

Although locum tenens may be retained for no longer than 60 days, the arrangements may be for fewer days if, for example, the cardiologist goes on an extended vacation or requires two weeks to go to a specialized training course. Locum tenens may even cover for the cardiologist for certain parts of the day, as described in the scenario above.

In this case, the morning encounter that determined the need for the heart cath should be reported using the appropriate subsequent inpatient care codes (99231-99233). A consultation code should not be used because the patient was admitted the night before by the locum, who is the "same" physician in the eyes of the carrier.

Callaway says, "Unless the admit and the follow-up encounter take place on different days, only the admission provided by the locum may be reported. It must be documented properly because a subsequent visit cannot be reported for the same patient on the same day as an admission by the same physician."

Among private payers, locum requirements are carrier-specific. Some require that the practice hiring the locum fill out a form to ensure the substitute physician is properly credentialed, says Linda Laghab, CPC, coding manager with Pediatric Management Group at Los Angeles Childrens Hospital. "The problem with that was that by the time we got the form back, the locum was gone," she says.

Laghab says that at the cardiology practice for which she previously worked, services provided by a locum were always identified as such in the claim form. That way these services could not be confused with "incident to" services, which involve ancillary health professionals or technicians providing services in the physicians name. Such services need to be performed under the direct personal supervision of the physician, which means the cardiologist must be in the medical suite.

"The locum, on the other hand, does not require any supervision, and the original physician doesnt have to sign off on the locums documentation," Laghab says. "Because the fact that a locum provided the service is documented, an auditor who notes the absence of the original physician will not assume a documentation error was made."

Note: Records of services provided by a locum tenens physician should be kept on file because they must be available upon request to carriers.