Locum Tenens & Reciprocal Billing. Modifiers Q5 and Q6

Transcription

1 Locum Tenens & Reciprocal Billing Modifiers Q5 and Q6 Presented by Part B Provider Outreach and Education September 21, 2016

2 Housekeeping Tips Dial-in number: Conference code: If you have any difficulties during the webinar you can: Chat with the host and presenter 2

3 Housekeeping You can take notes while viewing the presentation 3

4 Agenda Topics What is Reciprocal Billing What is Locum Tenens Billing Modifier Q5 Modifier Q6 Claim Submission Errors References 4

5 Disclaimer Please Read This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. 5

6 Reciprocal Billing Policy Regulations Regular physician is unavailable on an occasional reciprocal basis For example, emergency visits or weekend calls Arrangements need not be in writing Substitute physician does not provide the visit services over a continuous period of longer than 60 days Billing requirement of modifier Q5 must be used 6

7 Reciprocal Billing Payment Guidelines A physician may have reciprocal arrangements with more than one physician Services payment determined as though regular physician provided services Identification of substitute physician for audit trail to verify services were performed Advance Beneficiary Notice of Noncoverage (ABN) given in the name of the regular physician 7

8 Reciprocal Billing Compliance Requirements Record of each service provided by substitute physician must be kept on file Must be made available upon request Identification of the Q5 modifier certifies requirement has been met and that the regular physician is allowed to submit the claim 8

9 Reciprocal Billing Continuous Period of Covered Visits Billing cycle begins the first day the substitute physician provides covered visits** to the Medicare beneficiary Ends on the last day the substitute physician provides covered visits to the Medicare beneficiary New billing cycle begins once the regular physician has returned to work **Covered visit service includes not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as incident to the physician s services 9

10 Reciprocal Billing Example Regular physician goes on vacation June 30 and is expected to return on September 4 Substitute physician sees first Medicare beneficiary of regular physician on July 2 Including various times between August 30 and September 2 The continuous period billing cycle runs from July 2 through September 2 A period of 63 days September 2 is outside 60 day period Regular physician may bill and receive payment for services provided on his/her behalf in the period of July 2 through August 30 10

11 Locum Tenens Background Widespread practice for physicians to retain a substitute physician in their absence Illness, pregnancy, vacation or continuing medical education Substitute physician generally has no practice of his/her own Moves from area to area as needed Payment is made on a fixed amount per diem 11

12 Locum Tenens Payment Procedure Regular physician will submit the claim of covered visit services Locum tenens is one that is not an employee of the regular physician Services of locum tenens are for patients of regular physician and not restricted to the regular physician s offices, if 12

13 Locum Tenens Policy Regulations Regular physician is unavailable An arrangement has been made Payment made on a per diem or similar feefor-time basis Substitute does not provide the visit over a continuous period of longer than 60 days Claim submission will be identified with modifier Q6 13

14 Locum Tenens Regular Physician Guidelines Physician that is normally scheduled to see the Medicare beneficiary (patient) May include physician specialists such as cardiologist, oncologist and urologist Post-operative services furnished during period of covered global fee should not be identified on claim as substitution services Regular physician includes a physician who has left the group A locum tenens hired as a replacement Services are billed up to 60 days 14

15 Locum Tenens Billing Guidelines Regular physician will bill and receive payment for substitute s services You should bill the claim using the regular physician s National Provider Identifier Modifier Q6 is submitted on the claim line detail Keep a record of the substitute physician s NPI on file Resource found in the CMS, IOM Pub , Chapter 1, Section

16 Commonly Billed Errors Modifiers Q5 and Q6 Claims denied with modifiers Q5 and Q6 revealed the following: Duplicate claim denials Missing/incomplete primary identifier Missing ordering/referring provider Beneficiary eligibility Missing/incomplete Medicare number Hospice coverage Managed care plan coverage (e.g., HMO) Medicare secondary 16

17 Commonly Billed Errors Duplicate Claim Denials Clarification of Detection of Duplicate Claims Section of CMS IOM Alerts providers of claim editing for duplicate claims and suspect duplicate claims Exact duplicates have auto-denial edits Suspect are suspended and reviewed and-education/medicare- Learning-Network- MLN/MLNMattersArticles/downloa ds/mm8121.pdf 17

18 Commonly Billed Errors Missing/incomplete primary identifiers No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless enrolled in the Medicare program Each provider and supplier enrolls with the appropriate Medicare contractor Offices should make sure they have submitted an 855I (individual) and/or 855R (group member) to enroll new providers Visit the Cahaba Website for information on the Enrollment Process 18

19 Commonly Billed Errors Missing ordering/referring provider Affordable Care Act requires physicians, or other eligible nonphysician practitioners to enroll in the Medicare program to order/refer for beneficiaries Requirements You must have an individual NPI You must be enrolled in an approved or opt-out status You must be eligible to order/refer Education/Medicare-Learning- Network- MLN/MLNProducts/Downloads/MedEn roll_orderreferprov_factsheet_icn pdf 19

20 Commonly Billed Errors Beneficiary Eligibility Verify eligibility with our self-service options Interactive Voice Response Toll free: InSite Provider Web Portal /start.swe?swecmd=login&swecm =S&SWEHo=insite.cahabagba.com 20

21 Avoid Common Mistakes Things to Remember Non-physician practitioners can not bill for locum tenens or reciprocal billing services Do not bill for locum tenens services while waiting for a physician to be credentialed Locum tenens does not apply for a deceased provider 21

22 Reference Modifier Descriptors A modifier is a two-position code that is added to the end of a procedure code to clarify the services being billed Q5 modifier Services furnished by a substitute physician under a reciprocal billing arrangement Q6 modifier Services furnished by a locum tenens physician Modifiers Q5 and Q6 are considered informational They do not control pricing 22

23 Reference Bookmark Your Favorites Cahaba Centers for Medicare and Medicaid Services (CMS) CMS Internet Only Manuals Guidance/Guidance/Manuals/Internet-Only-Manuals- IOMs.html 23

24 24 Cahaba Reminders Foresee Survey

25 Cahaba Reminders InSite Provider Portal It features the ability to submit a Redetermination or Reopening via the portal There is no charge to use the system 25

26 Cahaba Enhancements Opt out Downloadable Listing Ability to sort in ascending and descending order Name, address, specialty, effective date and ending date Download a listing by state or all 26

27 Question & Answer To ask a question the caller should Dial the call-in telephone number at: Conference code: For claim specific questions call Provider Contact Center:

28 Thank You for Your Participation! Interactive Evaluation on WebEx Select the Survey Tab at the top of your screen, enter your responses, and click the submit button OR Submit your evaluation by accessing the link sent in your reminder scribe/survey?f=1773&x=ab0ca679 28