Medicare Compliance & Reimbursement

Question: We have a small practice in a designated health professional shortage area (HPSA). Because our physician on regular duty fell ill, we got an HPSA physician to substitute for his services as a locum physician. That morning, the locum physician performed chemotherapy for the patient. The patient reports to the practice again that evening, and an HPSA physician performed a level-three E/M service. We have a signed advance beneficiary notice (ABN) on file for the patient. Can you provide guidance for what modifiers we can append for multiple services?

Georgia Subscriber

Answer: You’re going to need several modifiers for this E/M service, including modifier 99 (Multiple modifiers). You will also need to check if your payer recognizes it. Coders should use modifier 99 when the number of modifiers for a claim line are more than the fields available on the claim form. Be sure to list all modifiers in item 19 on the CMS-1500 claim form.

Coding: Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) for the E/M with modifier Q6 (Service furnished under a fee-for-time compensation arrangement by a substitute physician…) for the substitution by another physician. Modifier Q6 implies the physician who performed the E/M is “filling in” for the ill physician on a locum tenens basis. You also need to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code because the patient received chemotherapy earlier that day from the same physician.

Additionally, you need to append modifier AQ (Physician providing a service in an unlisted health professional shortage area [HPSA]) because the physician is providing the service in a HPSA. Lastly, because the patient had a procedure performed by your surgeon, you need to add modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) as well.

You will want to report your modifiers in order of payment and significance to be properly reimbursed. The order of these would be the 24, 25, AQ, and Q6. All of these are important. The 25 shows payment should be made separate and apart from the infusion procedures the same day. Modifier 24 indicates it is unrelated to a recent procedure within the global period. Modifier AQ adds money to your service. Lastly, the Q6 is an important informational modifier; it indicates a locum tenens physician is providing certain services on behalf of the treating physician under a temporary arrangement.

Do this: In this case, there are more modifiers than you could fit on a standard claim form. You may put modifier 99 in box 24D on the same line as the service and list the other modifiers in box 19. If you have fewer than four modifiers, list them on the claim without modifier 99, as it is not necessary.