ED Coding and Reimbursement Alert

When the regular doctor is out, follow these rules when coding for the replacement physician

When one of your physicians takes a leave of absence and the ED hires a substitute physician to fill in, you must take extra coding steps on Medicare claims to ensure payment for the sub's services.

Why? When your ED employs a substitute, or locum tenens, physician, Medicare wants to see specific modifiers on claims. Further, your ED must observe time limits for locum tenens doctors. Otherwise, Medicare won't pay for their services.

You Can't Hire Locum Tenens Doctor as Extra Staff

There are a number of instances in which your ED might employ a locum tenens physician, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.

For example, you might need a substitute if one of your regular doctors:

- goes on vacation.

- has an illness that requires extended recovery time.

- goes on maternity or family health leave.

- takes a leave in order to attend continuing medical education sessions. 

Caveat: Remember that these substitutes cannot be hired to give your ED staff another doctor's services. -A locum tenens cannot be used to provide additional help, such as staffing for another operating room. The locum tenens doctor must always be used as a replacement who substitutes for a specific physician,- Hammer says.
 
Remember Q6 on All Locum Tenens Claims

Coding for locum tenens involves several extra steps in order to file an acceptable claim, Hammer says.

Here's a quick primer on the basic rules of locum tenens for Medicare providers:

- You must attach modifier Q6 (Service furnished by a locum tenens physician) to all codes for procedures performed by the substitute physician. This lets the Medicare carrier know that you are coding for a locum tenens physician. -Enter modifier Q6 to the procedure code in item 24d of the CMS-1500 claim form or in the corresponding field for electronic claim submissions,- Hammer says.

Without the modifier, you-ll likely receive a denial for the claim.

Suppose one of your ED physicians goes on maternity leave. Your locum tenens physician provides a Medicare patient with level-two E/M service and a control of a simple nasal hemorrhage.

On the claim, attach modifier Q6 to the E/M code (99282, Emergency department visit for the E/M of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem- focused examination; and medical decision-making of low complexity) and to the nosebleed treatment code (30901, Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) to show that a locum tenens doctor provided the services.

- The locum tenens physician must perform all services in the absentee physician's office. -Any hospital services would be billed through the absentee physician's office as well,- Hammer says.

- When a locum tenens physician works in your ED, the absentee physician must keep on file a record of each service provided by the substitute physician in his absence. You want to keep this information on hand in case the carrier wants to view it.

- All services the locum tenens doctors renders must be billed to Medicare under the billing ID of the regular doctor. -Since locum tenens physicians are not directly contracted with Medicare for the care of those patients, all claims need to be filed under the absentee physician's name and number,- says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC-approved instructor and contractor for The Coding Source in Oregon.

Observe 2-Month Limit for Substitute Doctors

Another important rule to remember for locum tenens doctors is that they cannot fill in forever. -For Medicare, the maximum is no longer than 60 continuous days starting with the first date of services provided by thelocum tenens physician,- Hammer says.

Also, proceed with caution if you-re considering billing locum tenens with any non-Medicare insurers. While Medicare payers recognize the term, private payers may not, Felthauser says.

Before filing a locum tenens claim with a private insurer, -verify with the plans as to their requirements for locum tenens billing -- and whether or not they even recognize it,- he says.

Try this: You are contacting a private insurer to see if they accept locum tenens services. Hammer recommends that you ask these questions:

- Do you recognize modifier Q6?

- Which provider's ID should be reported for the services?

- Does the locum tenens provider need to be credentialed with the payer, even if only temporary privileges?