Medicare Compliance & Reimbursement

Tip: Manage modifiers correctly to ensure clean claims.

Medicare providers work hard day in and day out. And with summer looming in the not so distant future, many will be heading out to enjoy a little rest and relaxation. Before you ride off into the sunset, ensure your practice has its ducks in a row on the rules about physician coverage.

Home in on Reciprocal Billing

There are two separate medical provisions for physician coverage. The first is reciprocal billing. This type of Medicare arrangement allows "covered visit services which the regular physician or physical therapist arranges to be provided by a substitute physician or physical therapist on an occasional reciprocal basis," according to CMS guidance.

Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, describes reciprocal billing this way: "Suppose a physician, Dr. A, goes on vacation and arranges for a colleague in town, Dr. B, to provide services in his absence. Under a reciprocal billing arrangement," Moore continues, "Dr. A can bill for the services Dr. B provided to Dr. A's patients while Dr. A was on vacation."

Chapter 1, Section 30.2.10 of the Medicare Claims Processing Manual outlines this important service. Highlights from the CMS guidance include the following key components of reciprocal billing:

• The regular physician is unavailable to provide the service;
• The patient has arranged, or seeks to receive, the service from the regular physician;
• The substitute only provides services to Medicare patients for no more than a period of 60 consecutive days; and
• The regular physician submits the claim for the services using HCPCS modifier Q5 (Service furnished under a reciprocal billing arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area).

Exception: There are always exceptions to the rule under Medicare and reciprocal billing is no different. Should you be called to active duty in the Armed Forces, CMS waives the 60-day limit to reciprocal billing, and you may bill for services furnished under the arrangement for longer than the time otherwise allowed by the regulations.

Know These Locum Tenens Basics

Another possible solution is locum tenens (LT), which is defined in detail in Chapter 1, Section 30.2.11 of the Medicare Claims Processing Manual. This type of coverage refers specifically to a physician who substitutes for other physicians when they're absent for things like illness, pregnancy, vacation, continuing medical education, and sabbatical.

Interesting: "Locum tenens do not generally participate in the Medicare program, often moving to wherever they're needed," reminds MAC Noridian Healthcare Solutions, LLC in a webinar on the subject.

NPI lowdown: It's wise to remember that an LT is a substitute for a regular physician, not a temporary hire for a busy practice - LTs are not contractual employees. In fact, though they may have their own NPIs their services are always billed under the regular physician's NPI.

"You can mention the locum's NPI number in the records, but it is not a requirement. If you do, put the locum's NPI in block 19," notes Noridian. "Always bill with the absent, regular physician's NPI and make sure you reflect the locum in the documentation."

60-day limitation: The arrangement always notes that an LT cannot work for more than 60 continuous days for the physician she is covering. That time period can include weekends, and the locum cannot skip days during that time and then continue after the agreed-upon 60 continuous days. However, "if the regular physician is part of a group with many doctors, the locum can come back and work for a different physician when his 60 days are up," Noridian advises.

The only exception to this rule, which is similar to that of reciprocal billing, is when the regular physician is called to active duty, in which case the LT's time of service can be unlimited.

MD or DO only: There are medical restrictions when hiring LTs for your practice. CMS requires that the LT be an MD or DO, and there are no exceptions. "Non-physician practitioners cannot have locum during their absences," says Noridian. In addition to medical specialists like cardiologists, urologists and others, an LT can also be utilized in the areas of general medicine, osteopathy, podiatry, dental surgery, optometry, and chiropractic services.

Tip: It's important to remember that an LT can be substituted for a "hospice patient's attending physician," but modifier GV (Attending physician not employed or paid under arrangement by the patient's hospice provider) must be attached to the code along with modifier Q6.

Take Care with Modifiers

It's critical to bill under the name and absent physician's NPI number to avoid denials. You need to append modifier Q6 (Service furnished under a fee-for-time compensation arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area) to any code you're using to cover the LT's care.

Though they may look familiar, there is a huge difference between modifiers Q5 and Q6. As Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC, puts it, "the difference between the modifiers is that Q6 is applicable to locum tenens arrangements more than the federally qualified arrangement for which Q5 is used."

Consider This Expert Advice

For physicians, CMS defines covered visit services as "not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as 'incident to' the physician's services."

In other words, as Blanchard and Moore point out, most primary care services a substitute physician provides on behalf of your doctor are covered under a reciprocal billing arrangement. Additionally, the service can be provided incident-to by a medical staff member other than the physician, providing the physician is present and your practice bills the service under the NPI number associated with your own physician or practice.

Resource: To review CMS guidance on reciprocal billing arrangements and locum tenens in Chapter 1, Sections 30.2.10 and 30.2.11 of the Medicare Claims Processing Manual, visit www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf.