Neurosurgery Coding Alert

Question: One of the neurosurgeons in our group is expecting a baby and will be taking maternity leave. Until this neurosurgeon returns from leave, we are turning her patient load over to a substitute physician. Are there any special rules we should observe when reporting services the substitute provides?

Connecticut Subscriber Answer: The coding department will need to adhere to locum tenens guidelines on all Medicare claims. Otherwise, Medicare will likely deny payment for the substitute's services.

Do this: When you report encounters in which a locum tenens doctor treats a Medicare patient, always append modifier Q6 (Service furnished by a locum tenens physician).

For example, your substitute neurosurgeon performs a posterior lumbar two-level laminectomy on an established Medicare patient.

On the claim, you should:

- report 63005 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy [e.g., spinal stenosis], one or two vertebral segments; lumbar, except for spondylolisthesis) for the laminectomy.

- bill under the absent physician's provider number, but indicate the substitute's UPIN (or NPI).

- attach modifier Q6 to 63005 to show that a substitute physician provided the services. Private-payer alert: Some non-Medicare insurers may also accept Q6 on a claim, but you-d be best served to call any private payer to see if they recognize modifier Q6 before using it on a claim.
 
Some carriers will follow the locum tenens guidelines, but some will not. In fact, due to liability concerns, most private payers will require any substitute to be credentialed in his own right.

Also, locum tenens physicians cannot fill in at a practice for more than 60 days in a row. Once the substitute has worked 60 straight days, he must bill for services in his own name.
 
Try this: If a locum tenens physician reaches the 60-day limit and the office still needs him to fill in, have the physician complete the CMS 855R form, which would reassign the temporary physician's Medicare benefits to the practice.
 
Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.