Practice Management Alert

Question: We have a small practice in a designated health professional shortage area (HPSA). Our physician fell ill, so we got an HSPA physician to fill in on a on a locum tenens basis. That morning, the locum physician performed chemotherapy for the patient. The patient reports to the practice again that evening, and an HSPA physician performed a level-three E/M service. We have a signed advance beneficiary notice (ABN) on file for the patient. I’m having trouble deciding which modifiers to use for the E/M service. Can you help?

Illinois Subscriber

Answer: You’re going to need several modifiers for this E/M code, including, modifier 99 (Multiple modifiers) if your payer recognizes it. Coders should use modifier 99 when the number of modifiers for a claim line are more than the fields’ availability on the claim form.

Coding: 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…) for the E/M with modifier Q6 (Service furnished by a locum tenens physician) attached to show that 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. Plus, because your office has an ABN a signed by the patient on file, you need to include GA (Waiver of liability statement issued as required by payer policy, individual case) as well. You will want to report your modifiers in order of payment and significance. The order of these would be the AQ, 25, Q6, and GA. All of these are payment modification modifiers, so you want to put them in payment order. The AQ adds money to your service. The 25 shows payment should be made and the Q6 is more informational, but does say to pay to the claim. The GA is also information around payment and can added last.

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 had fewer than four modifiers, modifier 99 wouldn’t be necessary.