Neurosurgery Coding Alert

Obtaining reimbursement from Medicare for procedures performed by substitute neurosurgeons can be tricky because of confusion regarding use of the appropriate modifiers and the billing options available. It is essential to understand the choices, which include reciprocal billing, billing for each service separately, and locum tenens.

Options for Substitutes

Neurosurgeons temporarily unable to care for their patients have three billing options:

Enter into a reciprocal billing arrangement with one or more neurosurgeons,whereby the substituting physician performs the service but the original doctor bills for it;

Provide services to each others patients and bill for each service or procedure performed under ones own provider number; or

If the neurosurgeon is going to be unavailable for an extended period, or has left the practice, or cannot reciprocate coverage, a locum tenens physician can perform the service, which is billed under the absent doctor's provider number.

The advantage of the first option reciprocal billing is that the neurosurgeon who is unavailable still gets paid, even while away. For the substituting neurosurgeon, the benefit is that a new billing account does not need to be opened for a patient who is unlikely to visit again because he will probably return to his regular physician.

The reciprocal billing guidelines in CPT 2001 state: In the instance where a physician is on call for or covering for another, the patients encounter will be classified as it would have been by the doctor who is not available. For example, even though this may be the first time the substitute neurosurgeon is meeting with this patient, it is not categorized as a new patient visit (99201-99205) or as a consultation (99241-99245), but is an established patient visit (99211-99215). This is because the second doctor has access to the patients medical record from the originating neurosurgeon and does not need to complete a full history and physical.

Reciprocal coverage is used when a physician is ill or on vacation, says Cynthia Thompson, CPC, a coding and reimbursement specialist with Gates, Moore and Co., an Atlanta consulting firm. For example, it might be used when a neurosurgeon undergoes surgery personally and is unable to work, but not long enough so that he or she wants to bring in a locum tenens, Thompson says.

Note: Locum tenens refers to retaining substitute physicians to temporarily take over professional practices in the absence of the regular physician (up to 60 continuous days) for reasons such as illness, pregnancy, vacation, or continuing medical education. If the regular physician returns to practice for even a single day, the 60-day period begins again. The regular physician bills and receives payment for the substitute doctor's services as though he/she performed them. The substitute physician generally has no practice of his/her own and moves from area to area as needed. The regular physician generally pays the substitute a fixed amount per diem, as an independent contractor.

Locum Tenens Scenario

Reciprocal billing is often confused with locum tenens, Thompson says. However, there are two main differences:

Reciprocal billing requires real reciprocity, that is, both physicians cover for each other in roughly equal proportions;

Locum tenens are usually paid on a per diem rate, by the absent doctor.

Under both arrangements, the patients unavailable neurosurgeon bills as though he or she performed the service.

And, whereas locum tenens arrangements are identified on the HCFA claim form by using HCPCS modifier -Q6 (service furnished by locum tenens physician), the reciprocal billing arrangement is indicated with modifier -Q5 (service furnished by a substitute physician under a reciprocal billing arrangement). Although locum tenens arrangements have been in wide use for years, as payment, it is based on a Medicare rule. These modifiers may also be used with third-party carriers, but make sure to ask your top five carriers how they want services performed.

Criteria for Billing Substitutes

According to the Medicare Carriers Manual (MCM) section 3060.6, The patients regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered services (including emergency visits and related services) that the doctor arranges to be provided by a substitute physician on an occasional reciprocal basis, if:

The regular physician is unavailable to provide the visit services;

The Medicare patient has arranged or seeks to receive the visit services from the originating doctor;

The substitute physician does not provide services to Medicare or third-party patients over a continuous period of longer than 60 days; and

The regular physician identifies the services as substitute services meeting the requirements of this section by entering the -Q5 modifier in item 24d of the HCFA 1500 claim form.

The guidelines for reciprocal billing and the use of the -Q5 modifier also apply to neurosurgeons in the same group practice. Medicare and third-party payers want to know if a different neurosurgeon provided the billed service even if both physicians are in the same group and use the same tax identification number.

The guidelines also state that the substitutes unique physician identification number (UPIN) must be included in box 23 of the HCFA 1500 claim form, Thompson notes, to inform Medicare of the identity of the physician who saw the patient.

For example, if a substitute neurosurgeon had to perform brain surgery on a patient, the -Q5 modifier would be appended to each code as follows:

61510-RT-Q5 for brain tumor excision on the right side of the brain; and

61312-LT-59-Q5 for hematoma removal on the left side of the brain.

Note: If the -Q5 modifier is not attached, the claim may be denied because the Medicare carrier will see a claim under one physician's billing number, whereas the UPIN indicates the service was performed by another provider. As the substituting neurosurgeon did not file a claim, no payment for the service will be made.

Reciprocal billing arrangements are often used with hospital admissions, says Laurie Castillo, MA, CPC, president and curriculum instructor of the American Association of Professional Coders, Northern Virginia Chapter, and owner of Physician Coding & Compliance Consulting, a consulting firm in Manassas, Va.

For instance, if neurosurgeon B is covering for doctor A for the weekend and has to admit a patient, reciprocal billing would apply. When doctor A returns, hell take over the patients care. Therefore, neurosurgeon B admits the patient but doesnt bill for the admission (99221-99223). Instead, doctor A bills for the service, making sure to include both the -Q5 modifier and neurosurgeon Bs UPIN.

According to MCM section 3060.6, a physician may have reciprocal arrangements with more than one alternate physician, and they do not need to be in writing. However, the substitute neurosurgeons UPIN should be kept on file. Also, there should be documentation in the medical records of all patients seen.

Follow-up on Patients in a Global Period

If the services provided by the substitute neurosurgeon are considered part of a surgical global period (for example, follow-up care on a patient after spinal surgery), modifier -Q5 is not needed, according to MCM section 3060.6, because the services are bundled with the original procedure performed by the original neurosurgeon.

If, however, the patient has a separately identifiable problem, the visit could be billed by the regular neurosurgeons office with modifiers -24 (unrelated evaluation and management service by the same physician during a postoperative period) and -Q5 attached. For example, if a patient had spine surgery and then came to the substitute doctor because of a pain in his right wrist, which was not connected to the previous surgery, then the substitute could code for that visit with the established office visit codes (99211-99215) with modifier -24.

If the original neurosurgeon became unavailable immediately after performing a procedure, and the substitute performed the majority of the follow-up care and doesnt have a reciprocal or locum tenens arrangement with the unavailable neurosurgeon, he or she may be able to bill for this by attaching modifier -55 (postoperative manage-ment only) to the code for the procedure performed.

For example, the covering neurosurgeon could bill for a follow-up office visit with a patient who had intracranial aneurysm surgery performed as a 61700 with modifier -55 attached to show that the visit was for postoperative management. Such a claim may not be paid unless the office of the neurosurgeon who performed the procedure agrees to attach modifier -54 (surgical care only) to the original service, indicating that postoperative care would be handled by another physician. In these cases, the fee charged by the original neurosurgeon should be reduced to reflect the fact that postoperative services are not included.

Note: You may check the intra- and post-operative proportions listed in the Medicare Physicians Fee Schedule Database for guidance in setting these fees.

This can be accomplished by determining the cost for the surgical procedure alone, not including postoperative care, and billing that amount to the insurance carrier. Modifier -54 should be appended to all of the appropriate neurosurgical codes.

Note: It is important to know that a locum tenens is not to be used as a permanent replacement for an absent physician, i.e., for more than 60 continuous days. This situation would require the substitute doctor to be hired and credentialed in his or her own right. Medicare claims may be held and submitted after this process is complete, but this is not the case with many payers, who may deny services with no chance for later submission. The inability to submit retroactive claims can cause difficulties since credentialing may take up to 6 months or more.