Neurology & Pain Management Coding Alert

Do you know which modifier you should use for a ‘substitute’ physician?

When your practice is a physician short for whatever reason — vacation, maternity leave, sabbatical, etc. — your practice might shift their case load to the other physicians on staff. The practice might also hire a physician to fill in for the physician who is out, thereby introducing a new provider into your coding world, at least temporarily.

When you are coding for a substitute physician’s services, you must observe locum tenens (LT) protocols, or you could miscode the claim.

Check out what the experts had to say about the ins and outs of LT coding.

Use LT for Fill-Ins, not Extra Help

First, know that LT is a Medicare protocol. That’s not to say other payers don’t follow LT guidelines, but there’s no guarantee that they do. Feel free to observe these rules for any Medicare payer, but proceed with caution when considering these guidelines for a private payer. They could have vastly different rules for billing for substitute physicians.

When you code LT, “you are billing for a covering physician as if they were the regular physician. Medicare has certain parameters that need to be met in order to bill locum tenens and many other insurance companies adopt similar policies,” explains Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO of CCO.us. “The coverage is usually for an extended period of time. Most locum tenens physicians don’t have their own practice.”

Also: “LT is a physician who is substituting for a practice’s paid physician for no more than 60 days,” reminds Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey. And lastly, the physician must be substituting for another physician — they can’t be hired as “extra help.”

“The LT physician must be substituting for a physician within the practice and not a contractual employee/ physician of the practice,” Brink continues.

Use Absent Doc’s NPI for LT

When you code for the LT physician’s services, be sure to use the absent physician’s National Provider Identifier (NPI) when reporting the service. For example, if an LT was filling in for Dr. X and performed a level-three evaluation and management (E/M) service for an established patient, you’d report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) under Dr. X’s NPI.

You’ll also want to make sure to use 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) on your LT physician’s claims.

Adding Doc to Staff an Option After 60 Days

As earlier noted, an LT physician can fill in for another physician for 60 continuous days starting with their first date of service. “If coverage is needed for longer than 60 days then the covering physician should be added to the group,” Jandroep says. Then they would get their own NPI number and bill under that instead of another physician’s.

Also, be aware that employing LT physicians could perk up the ears of auditors, and you’ll want to be ready with spot-on documentation that proves you’ve been coding LT correctly the entire time. “A practice must keep a record of all the services a LT physician provides under the subbing physician’s NPI number in case of an audit and for compliance with Medicare billing and coding guidelines,” Brink recommends.