Locum tenens billing with modifier Q6

Locum tenens is a confusing situation in the case where a physician takes a vacation or otherwise isn’t available and hires a physician to see patients on site, Medicare can deny the claim unless it is properly documented. The reason is that Medicare is very strict about seeing specific modifiers on medical billing claims that involve a substitute or locum tenens physician.

Further, your medical billing claim must have the time limits observed for locum tenens doctors. Otherwise, Medicare won’t pay for their services rendered to patients. Also, you can’t hire a locum tenens as extra staff. 

This includes situations where the regular attending physician goes on vacation, has an illness with a lengthy recovery time, maternity or family healthy leave, or educational reasons such as attending continuing medical education classes. When you use a locum tenens physician it must always be in the capacity as a temporary replacement that substitutes for the services of a specific physician.

Remember to use Modifier Q6 on all your locum tenens claims. There are some extra steps that must be taken in order for your locum tenens claims to be reimbursed by Medicare. The Q modifier should be listed as a procedure code so Medicare knows you’re claiming services rendered by a locum tenens physician. If you don’t use the modifier, you claim will likely be denied. 

Also the maximum time limit for billing for locum tenens physicians is currently sixty days for Medicare and private payers will have different criteria for length of service. Call before you file is a good rule of thumb, you may be missing reimbursements if you don’t. Some good questions to ask would be if the payer requires the locum tenens be credentialed even for a short period of service time; also, which provider’s ID would they prefer to be reported?

Using the correct modifier and a call before you file can save you a lot of hassles and delays in receiving your reimbursements for the locum tenens type of medical billing claims.

Hospice modifiers list GV,GW, GJ , Q5, Q6

Hospice Modifiers Fact Sheet

Definitions:

**  GV - Attending physician not employed or paid under agreement by the patient's hospice provider.

**  GW - Service not related to the hospice patient's terminal condition

**  Q5  - Service furnished by a substitute physician under a reciprocal billing arrangement

**  Q6 - Service furnished by a locum tenens physician

Modifier GJ "Opt out" physician or practitioner emergency or urgent services

Facts

** Modifiers are billed when a patient is enrolled in a Hospice.

** Modifier GW is used when a providers of services (physican, ambulance supplier, etc.) is performing services not related to the hospice diagnosis.

** Modifier GV is used when the physician performing services is not employed by the hospice and is designated as the attending physician.

** Certain Medicare beneficiaries can choose hospice benefits instead of Medicare for treatment and management of their terminal condition.

** The beneficiary waives all rights to Medicare Part B payments for services except for professional services of an “attending physician.” (In this case “attending physician” is defined as a doctor of medicine or osteopathy who is identified as having the most significant role in the determination and delivery of their medical care.)

** The professional services of an attending physician are not considered hospice services.

** The services of the attending physician are billed to Medicare Part B with modifier GV modifier Attending physician not employed or paid under agreement by the patient's hospice provider as long as the provider does not have a payment arrangement with the hospice. In the latter case the services are billed by the hospice to Medicare Part A.

** If a substitute or locum tenens physician provides services, the designated attending physician bills the services using modifier GV and either the Q5 or Q6 modifier.

Here are some examples to give a better understanding of the use of these modifiers:

Example 1: A beneficiary is enrolled in Hospice and goes to a physician's office for closed treatment of a metatarsal fracture, CPT code 28470.

Resolution: If the procedure is unrelated to the terminal prognosis (Non-Hospice related), the physician's bill should contain GW modifier (Service not related to the hospice patients terminal condition). If this modifier is not appended, the procedure is related to the terminal prognosis and should not be reimbursed under the part B benefit. Thus, the claim is in error, since the services are considered included with payments under the hospice benefit.

Example 2: The patient is listed as being on hospice starting August 1, 2010 through August 31, 2010. Then a provider billed CPT code 45378, Diagnostic Colonoscopy with no modifiers on August 3, 2010 to Part B.

Resolution: The billing of code 45378 would be incorrect since the beneficiary was enrolled in hospice and there can be no separate reimbursement unless the service was unrelated to the terminal prognosis or the attending physician was otherwise entitled to separate reimbursement, which would be reflected by GV modifier (Attending physician not employed or paid under arrangement by the patients hospice provider) or GW modifier (Service not related to the hospice patients terminal condition). 

MACs should also deny services that are submitted with the modifier but for which, during medical review, the service is determined to be related to the terminal prognosis.

Guidelines/Instructions for Modifier GV

The attending physician is not employed or paid under agreement by the patient's Hospice provider.

Instructions

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

Service was rendered to a patient enrolled in a Hospice.

Service was provided by a physician or non-physician practitioner identified as the patient's  'attending physician' at the time of that patient's enrollment in the Hospice program

Submit this modifier regardless of whether the services were related to the patient's terminal condition

Service was provided by a physician employed by the Hospice, you may not submit this modifier

Service was provided by a physician not employed by the Hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier

Example:  An independent attending physician or independent laboratory interprets the surgical pathology (88305) from a patient with a terminal illness related service. The professional component is billed to the Medicare contractor. If there is no professional component (e.g., clinical lab tests), then the Part A Hospice should only be billed.

Date of Service    Treatment   CPT/Modifier

01/14/12 Surgical pathology (professional component) Bill to Part B: 88305 26GV

01/14/12 Surgical pathology (technical component) Bill to Hospice: 88305 TC

Same rules apply for diagnostic tests

Date of Service  Treatment CPT/Modifier

09/25/12 Chest x-ray (professional component) Bill to Part B: 71010 26GV

09/25/12 Chest x-ray (technical component) Bill to Hospice: 71010 TC

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

The service was rendered to a patient enrolled in a hospice.

The service was provided by a physician or non-physician practitioner  identified as the patient’s “attending physician” at the time of that patient’s enrollment in the hospice program.

Submit this modifier regardless of whether the services were related to the patient’s terminal condition.

If the service was provided by a physician employed by the hospice, you may not submit this modifier.

If the service was not provided by a physician employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier.

For beneficiaries enrolled in hospice, MACs should deny any Part B services furnished on or after January 1, 2002, that are submitted without either GV modifier, meaning the attending physician is not employed or paid under arrangement by the beneficiary's hospice provider and professional services provided are related to the terminal prognosis, or GW modifier, meaning the service is not related to the hospice beneficiary's terminal prognosis. 

MACs should deny services that are submitted with the GW modifier when the service is determined to be related to the terminal prognosis. Also, MACs should deny services that are submitted with the GV modifier if it is determined that the Physician services were furnished by Hospice-employed physicians and Nurse Practitioners (NP) or by other physicians under arrangement with the Hospice.

HCPCS Modifier GV Description:

Attending physician not employed or paid under arrangement by the patient’s hospice provider.

Guidelines/Instructions:

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

** The service was rendered to a patient enrolled in a hospice.

** The service was provided by a physician or non-physician practitioner identified as the patient’s “attending physician” at the time of that patient’s

enrollment in the hospice program.

** Submit this modifier regardless of whether the services were related to the patient’s terminal condition.

** If the service was provided by a physician employed by the hospice, you may not submit this modifier.

** If the service was not provided by a physician employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier.

Guidelines/Instruction for Modifier GW

Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient’s terminal condition. All providers must submit this modifier when this condition applies.

For services provided to beneficiaries enrolled in hospice, all providers must submit one of the above applicable modifiers on the detail service line for the service.

Services submitted for a “hospice” beneficiary without one of the hospice modifiers will be denied