Reciprocal Billing and Locum Tenens. Presented by: Medicare Part B Provider Outreach and Education (POE) May 2016

Transcription

1 Reciprocal Billing and Locum Tenens Presented by: Medicare Part B Provider Outreach and Education (POE) May 2016

2 Disclaimer This information release is the property of Noridian Healthcare Solutions, LLC (Noridian). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. May

3 Acronyms APN CFR CNM CNS CP CSW MPFS NP NPI NPP PA PT OT Advanced Practice Nurse Code of Federal Regulations Certified Nurse Midwife Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Medicare Physician Fee Schedule Nurse Practitioner National Provider Identifier Non Physician Practitioner Physician Assistant Physical Therapist Occupational Therapist May

4 Agenda Reciprocal Billing Locum Tenens Resources Reminders May

5 Objective To better understand Medicare Part B guidelines as it relates to Reciprocal Billing and Locum Tenens Arrangements May

6 Reciprocal Billing Arrangements

7 Payment under Reciprocal Arrangement Arrangement between two physicians to substitute for one another Regular physician not available E.g. emergency visits/weekend calls Arrangements need not be in writing No more than 60 days Substitute physician name and NPI may be placed in Item 19 or Comments Field NOT required Use modifier Q5 May

8 Payment Determined as though regular physician provided services Identification of substitute physician for audit trail to verify services were furnished Not for purposes of payment or limiting charge Advance Beneficiary Notice of Noncoverage (ABN) given in the name of the regular physician May

9 A Continuous Period of Covered Visit Begins the first day the substitute physician provides covered visits to beneficiary Ends the last day the substitutes physician provides covered visits to beneficiary New period begins after regular physician returns to work May

10 Example of Covered Visits Services Regular physician vacation begin June 30 Regular physician vacation ends September 4 Substitute physician FIRST sees beneficiary July 2 and various other times including August 30 and September 2 Continuous period is from July 2 September 2 63 days September 2 is outside 60 day period Substitute physician must bill for September 2 visit Regular physician may bill for July 2 and August 30 visits May

11 Physician in the Same Group Reciprocal billing does not generally apply to substitution arrangements among physicians in same group Claim submitted in the group name/npi Group physician who performed service must be identified Exception: Group member provides services for another group member designated as attending for hospice Q5 modifier used by designated attending physician when another group member performed services In addition to the GV to show attending May

12 Additional Information If the substitution is ONLY for global post op period services are included in the global fee No need to be identified as substitution May have reciprocal arrangements with more than one physician Record of each service provided by substitute physician must be kept on file with the regular physician Available upon request Q5 modifiers certifies requirements met and regular physician entitled to submit claim May

13 Locum Tenens Coverage

14 Overview Locum Tenens defined as physicians who substitute for other physicians when absent for: Illness Pregnancy Vacation Continuing Medical Education Sabbatical Under arrangement Physician pays locum per diem Typically no practice of their own Locums move from area to area as needed May

15 The Regular Physician Regular physician is who is normally scheduled to see patients, includes specialists Cardiologist, oncologist, urologist, etc Within authorized scope of practice Medical necessity for visit must be met Documentation must clarify provider of service was locum tenens Along with documenting billing provider May

16 Timeframe Under arrangement no longer than 60 continuous days Current locum cannot take a day off to restart 60 days When regular physician leaves practice With physician permission to continue using his/her NPI, allowed up to 60 days Reflect information in documentation Watch that PTAN is not deactivated May

17 Locum Tenens Billing Regular physician bills with their own NPI Locum s NPI in medical record Locums Name/NPI may be placed in Item 19 or Comments Field Not required Use modifier Q6 Locum covering for hospice patient s attending physician Bill modifier Q6 with GV modifier May

18 Use of Locum Tenens Can Use Locum Tenens Medicine Osteopathy Podiatric Optometry Chiropractic Dental Surgery Cannot Use Locum Tenens Clinical Nurse Specialist Nurse Anesthetist Nurse Midwife Therapists OT, PT, SLP Psychologist Social Worker May

19 Deceased Providers Cannot use Locum Tenens Deceased Provider s Group or Executor Submit 855I and if needed 855R Include copy of death certificate End PTAN on date of death May

20 Resources

21 CMS Resources Claims for CMS Guidance Reciprocal Billing Arrangements IOM, 100-4, Chapter 1, Section Locum Tenens Arrangements IOM, Chapter 1, Section May

22 Reminders

23 Noridian Likes Website Feedback! Please provide constructive/complimentary feedback to continue Noridian website growth and improvement May

24 MSI Survey MAC Satisfaction Survey (MSI) Started May 2016 for Noridian only Approx. 10-minutes-quick multiple choice Contracting/MSI/ Let CMS know how Noridian is performing EDI, Appeals, Customer Service, self-service portal, IVR, Medical Review, Education, Enrollment and Overall Comments May

25 CEU Reminder Attend entire workshop to earn CEU(s) Take short polling survey Pops up after closing out of webinar CEU ed 3 days after presentation Earn 1 CEUs today No password/index number needed for AAPC PDF presentation ed again with CEU Q/A posted after 30 business days May

26 Questions Thank you