Pulmonology Coding Alert

Question: One of our pulmonologists is taking January off (an extended holiday). We have retained the services of another pulmonologist (as an independent contractor) to take her place while she is gone. Any advice on filing claims for work the substitute performs?

Minnesota Subscriber

Answer: It depends on the insurer. For Medicare, you must observe locum tenens reporting rules. These guidelines govern all services provided to Medicare patients by a substitute physician.

Explanation: The most important thing to remember when billing for substitutes is modifier Q6 (Service furnished by a locum tenens physician). You must append this modifier to every procedure code on a claim for a substitute physician.

You'll send the bill out under the regular physician's name, but modifier Q6 alerts Medicare that the services were actually provided by a locum tenens physician. The physician/group receives the payment for the billed services, and pays the substitute a per-diem rate.

So if the locum tenens physician provides a level-two E/M for an established patient, you should report 99212-Q6 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making).

Remember that the locum tenens physician cannot fill in for more than 60 straight days. Once the substitute has reached the 60-day limit, he must bill for his services under his own name.

Private payers vary: Before using modifier Q6 for a non-Medicare patient, check with the carrier. Some will follow the locum tenens guidelines, but you should not assume that all carriers will want modifier Q6. And their rules regarding substitute physicians could be very different from Medicare's.

Note: For more information on Medicare's locum tenens policy, go to www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.