Wiki Locum tenens and reciprocal billing arrangements

[krenatesmith]

I work for a surgical group and I am new to coding Locum Tenens.

My questions:

When our surgeon's assume care for a patient while they are still in the hospital AFTER a Locum Tenens performs a surgery, and we follow up with the patient due to complications from the surgery.....Example: Laparoscopic cholecystectomy,
how is this coded....Example: 47562,55 then the actual date the surgeon from our group saw Pt for follow-up?
If that patient is seen during their hospital stay by multiple providers in our practice, do we bill each service with 47562,55? In box 19 on the claim are we putting the actual date we assumed care and the end of the global period for this particular surgery?
My next question:

When our surgeon's assume care for a patient after the Locum Tenens performed a surgery at the hospital and discharged the patient from the hospital, what is the correct coding protocol for the follow up office visit after surgery? Example: 47562,55 and the actual date of surgery on the claim line, then in box 19 the date we assumed care?


Our practice has researched a few resources that have stated we need an actual transfer summary to attach to our claims. If the Locum Tenens provides this in his OP note "Locum Tenens performing the surgery", is this correct documentation that the insurance companies require, or do we need a separate document from the Locum Tenens?

The attached Medicare Learning Network states under the "Exceptions to the Use of Modifiers "54" and "55" ...."where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim." What is the correct interpretation of this? If we do not have the transfer summary documentation on file, we can code the follow up office visits from the Locum Tenens surgery without the surgical CPT code and just the appropriate E/M and no 55 modifier? We would also bill the date of service we saw the Patient in office and not the date of surgery?


Thank you

 

[jkyles]

Hi there, are the locum and the surgeon both working for your group? It sounds like the locum filled in for the surgeon and the surgeon is taking up the patients care after returning to work. Is that correct?

 

[krenatesmith]

Hi there, are the locum and the surgeon both working for your group? It sounds like the locum filled in for the surgeon and the surgeon is taking up the patients care after returning to work. Is that correct?

The locum's are contracted at the hospital. Our surgeon's have their own practice.

 

[sls314]

The locum's are contracted at the hospital. Our surgeon's have their own practice.

Who is the locum filling in for? How do you usually bill when you assume care from that surgeon?

 

[krenatesmith]

Who is the locum filling in for? How do you usually bill when you assume care from that surgeon?

The locum has been hired by the local hospital. He actually takes call for our group when our surgeons are unable to..... I am a 1099 employee for the hospital and when I code the surgeries for the locum, I use a 54,Q6 modifier on the surgery claim.

When the surgical group performs the follow up after surgery in office & hospital, we are coding the surgical CPT with a 55 modifier and placing the actual date of surgery on the claim. In box 19 we place the date our surgeon's assume care of the patient as well as the ending date of the global period. The follow up claims are being denied.

 

[krenatesmith]

Who is the locum filling in for? How do you usually bill when you assume care from that surgeon?

I have another question.....Is there a difference in the modifiers used if it's not a locum tenens but a 1099 contract provider? Example: 44970,54,Q6 (locum) or 44970,54 (1099 contract provider)

I really appreciate your help.

Thank you

 

[jkyles]

Locum tenens describes a specific arrangement when one physician (or phyisical therapist) temporarily stands in the place of a permanent member of the group who intends to return to work. So, Dr. A is going to serve as a guest lecturer at State University for a month and intends to return to the practice. Dr. Locum comes in and assumes Dr. A's position for that one-month period and then leaves when Dr. A returns. However, if Dr. 1099 comes in because there's a staffing shortage and they aren't taking a specific person's place for that 60-day period, then they aren't an lt.

But to further clarify - the substitute surgeon is affiliated with the hospital, not the surgical group, and the hospital and surgical group have different TINs, correct?

 

[krenatesmith]

Locum tenens describes a specific arrangement when one physician (or phyisical therapist) temporarily stands in the place of a permanent member of the group who intends to return to work. So, Dr. A is going to serve as a guest lecturer at State University for a month and intends to return to the practice. Dr. Locum comes in and assumes Dr. A's position for that one-month period and then leaves when Dr. A returns. However, if Dr. 1099 comes in because there's a staffing shortage and they aren't taking a specific person's place for that 60-day period, then they aren't an lt.

But to further clarify - the substitute surgeon is affiliated with the hospital, not the surgical group, and the hospital and surgical group have different TINs, correct?

Yes, the substitute surgeon is affiliated with the hospital, not the surgical group and both groups have different TIN's.

 

[csperoni]

There are 2 complicated legal/compliance/clinical situations here - Locum Tenens is one. Whether or not there is a formal transfer of care is the other.
I agree that this does not seem like a Locum Tenens scenario, which was described by @jkyles. The hospital who employs the physician should have credentialed them before even starting to see patients in order to bill for their services. The doctor performing the surgery should be billing under their own credentials without Q6. If this is a standard thing that the doctor performing surgery does not perform the postop care, and it is transferred to your group, there should be a written agreement regarding the transfer of care in each patient's medical record which does not seem to be currently occurring. If documented appropriately with a transfer of care supported:
Performing surgeon: CPT123-54
Surgeon group taking on postop: CPT123-55

From CMS Medicare Claims Processing:
Physicians Who Furnish Part of a Global Surgical Package
Where physicians agree on the transfer of care during the global period, the following modifiers are used:
• “-54” for surgical care only; or
• “-55” for postoperative management only.
Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.
Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.
EXCEPTIONS:
• Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code. No modifiers are necessary on the claim.
• If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with the “-55” modifier for the post-discharge care. The surgeon bills the surgery code with the “-54” modifier.
• Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. The physician who performs the emergency room service bills for the surgical procedure without a modifier.
• If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate evaluation and management code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.

These instructions are also referenced in the Medicare Global Surgery booklet.

I would strongly recommend involving appropriately trained legal and/or compliance professionals to evaluate the proper steps, particularly if this is an ongoing situation. While you may not have such personnel on staff at a private practice, the hospital must.

 

[jkyles]

Agreed that this is one that should be kicked to the hospital's compliance team or legal counsel. They will want to know what sort of denial codes you're getting.

 

[krenatesmith]

There are 2 complicated legal/compliance/clinical situations here - Locum Tenens is one. Whether or not there is a formal transfer of care is the other.
I agree that this does not seem like a Locum Tenens scenario, which was described by @jkyles. The hospital who employs the physician should have credentialed them before even starting to see patients in order to bill for their services. The doctor performing the surgery should be billing under their own credentials without Q6. If this is a standard thing that the doctor performing surgery does not perform the postop care, and it is transferred to your group, there should be a written agreement regarding the transfer of care in each patient's medical record which does not seem to be currently occurring. If documented appropriately with a transfer of care supported:
Performing surgeon: CPT123-54
Surgeon group taking on postop: CPT123-55

From CMS Medicare Claims Processing:
Physicians Who Furnish Part of a Global Surgical Package
Where physicians agree on the transfer of care during the global period, the following modifiers are used:
• “-54” for surgical care only; or
• “-55” for postoperative management only.
Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.
Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.
EXCEPTIONS:
• Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code. No modifiers are necessary on the claim.
• If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in-hospital postoperative care bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with the “-55” modifier for the post-discharge care. The surgeon bills the surgery code with the “-54” modifier.
• Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. The physician who performs the emergency room service bills for the surgical procedure without a modifier.
• If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate evaluation and management code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.

These instructions are also referenced in the Medicare Global Surgery booklet.

I would strongly recommend involving appropriately trained legal and/or compliance professionals to evaluate the proper steps, particularly if this is an ongoing situation. While you may not have such personnel on staff at a private practice, the hospital must.

Thank you for this information!

 

[krenatesmith]

Agreed that this is one that should be kicked to the hospital's compliance team or legal counsel. They will want to know what sort of denial codes you're getting.

Thank you!