Locum Tenens payment Guidelines with example



 Physician Payment Under Locum Tenens Arrangements - Claims Submitted to Carriers

A. Background

It is a longstanding and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the substitute physician’s services as though he/she performed them. The substitute physician generally has no practice of his/her own and moves from area to area as needed. The regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than of an employee. These substitute physicians are generally called “locum tenens” physicians.

Section 125(b) of the Social Security Act Amendments of 1994 makes this procedure available on a permanent basis. Thus, beginning January 1, 1995, a regular physician may bill for the services of a locum tenens physicians. A regular physician is the physician that is normally scheduled to see a patient. Thus, a regular physician may include physician specialists (such as a cardiologist, oncologist, urologist, etc.).

B. Payment Procedure

A patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices, if:

• The regular physician is unavailable to provide the visit services;

• The Medicare beneficiary has arranged or seeks to receive the visit services from the regular physician;

• The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis;

• The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days subject to the exception noted below; and

• The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished by a locum tenens physician) after the procedure code. When Form CMS-1500 is next revised, provision will be made to identify the substitute physician by entering his/her unique physician identification number (UPIN) or NPI when required to the carrier upon request.

EXCEPTION: In accordance with section 116 of the “Medicare, Medicaid, and SCHIP Extension Act of 2007” (MMSE), enacted on December 29, 2007, the exception to the 60-day limit on substitute physician billing for physicians called to active duty in the Armed Forces has been extended for services furnished from January 1, 2008 through June 30, 2008. Thus, under this law, a physician called to active duty may bill for substitute physician services from January 1, 2008 through June 30, 2008 for longer than the 60-day limit.

If the only substitution services a physician performs in connection with an operation are post-operative services furnished during the period  covered by the global fee, these services need not be identified on the claim as substitution services.

The requirements for the submission of claims under reciprocal billing arrangements are the same for assigned and unassigned claims.

C. Medical Group Claims Under Locum Tenens Arrangements

For a medical group to submit assigned and unassigned claims for the services a locum tenens physician provides for patients of the regular physician who is a member of the group, the requirements of subsection B must be met. For purposes of these requirements, per diem or similar fee-for-time compensation which the group pays the locum tenens physician is considered paid by the regular physician. Also, a physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may bill for the temporary physician for up to 60 days. The group must enter in item 24d of Form CMS-1500 the HCPCS modifier Q6 after the procedure code. Until further notice, the group must keep on file a record of each service

provided by the substitute physician, associated with the substitute physician’s UPIN or NPI when required, and make this record available to the carrier upon request. In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her provider identification number (PIN) or NPI when required on block 24J of the appropriate line item.

Physicians who are members of a group but who bill in their own names are generally treated as independent physicians for purposes of applying the requirements of subsection A for payment for locum tenens physician services. Compensation paid by the group to the locum tenens physician is considered paid by the regular physician for purposes of those requirements. The term “regular physician” includes a physician who has left the group and for whom the group has hired the locum tenens physician as a replacement.

Psychiatric and Substance Abuse Facilities


The information in this section pertains to members with PPO (BlueChoice, BlueMedicare PPO, and BlueOptions) and Traditional coverage.

Note: All behavioral health services for HMO members should be arranged through New Directions Behavioral Health, including submission of claims.

Intensive Outpatient Program

Intensive outpatient program is defined as treatment that lasts a minimum of three hours a day for a minimum of three days per week in a structured program.

• Indicate “131” type of bill with revenue code 0905 for psychiatric services and 0906 for substance abuse services. Do not bill revenue codes 0500 or 0914.

• For FEP members, IOP admissions must be certified.

Outpatient

Outpatient behavioral billing are for treatments that do not last longer than 80 minutes per day, and are eligible for payment based on the terms of the rendering MD, PhD, or licensed masters level clinician’s agreement. No more than one outpatient visit per day will be eligible for payment.

Partial Hospitalization (PHP)

Florida Blue defines revenue code 0912 as partial hospitalization for chemical dependency and revenue code 0913 as partial hospitalization for psychiatric services.

• Indicate “131” type of bill.

Note: For BlueCard members, you must contact the home plan to identify if the member’s benefit is identified as inpatient or outpatient and bill your claim to Florida Blue accordingly.

For BlueCard members, indicate “111” or “131” type of bill depending on the member’s benefits.

• For inpatient, indicate “111” type of bill with room and board revenue code 0169, and the applicable revenue code 0912 or 0913 on the following line. The days/units must be submitted on the line that contains revenue code 0169.

• If outpatient, indicate “131” type of bill with the applicable revenue code 0912 or 0913. Do not bill revenue code 0169.

For FEP members, indicate “131” type of bill with the applicable revenue code 0912 or 0913. Do not bill revenue code 0169.

New Directions Behavioral Health defines revenue codes 0912, 0913, and 0915 for use as partial hospitalization. The primary diagnosis will determine the per diem rate.

Medicaid Vaccine and Immunization CPT code list

Pediatric Flu Vaccine: Special Situations 

In the event a Medicaid provider does not have VFC pediatric influenza vaccine on hand tovaccinate a high priority VFC eligible Medicaid enrolled child, the provider should use pediatric influenza vaccine from private stock, if available. If a provider does use vaccine from private stock for a high priority VFC eligible Medicaid enrolled child, the provider would then replace dose(s) used from private stock with replacement dose(s) from VFC stock when VFC vaccine becomes available. The provider should not turn away, refer or reschedule a high priority VFC eligible Medicaid enrolled child for a later date if vaccine is available. Louisiana Medicaid will update Medicaid enrolled providers through remittance advices and the Louisiana Medicaid Provider Update regarding availability of vaccine through the VFC program and any billing issues. Please contact the Louisiana VFC Program office at (504)838-5300 for vaccine availability information.



* indicates the vaccine is available from the Vaccines For Children (VFC) program

^ indicates the vaccine is payable for QMB Only and QMB Plus recipients Vaccine

Code Description

90476^ Adenovirus vaccine, type 4, live, for oral use

90477^ Adenovirus vaccine, type 7, live, for oral use

90581^ Anthrax vaccine, for subcutaneous use

90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use

90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use

90632 Hepatitis A vaccine, adult dosage, for intramuscular use

90633* Hepatitis A vaccine pediatric/adolescent dosage, 2-dose schedule, for intramuscular use

90634* Hepatitis A vaccine, pediatric/adolescent dosage, 3-dose schedule, for intramuscular use

90636 Hepatitis A and Hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use

90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use

90646 Hemophilus Influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use

90647* Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use

90648* Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use

90649* Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use

90655* Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for
intramuscular use

90656* Influenza virus vaccine, split virus, preservative free, when administered to 3 years and older, for intramuscular use

90657* Influenza Virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use

90658* Influenza Virus vaccine, split virus, when administered to 3 years of age and older, for intramuscular use

90660* Influenza Virus vaccine, live, for intranasal use

90665^ Lyme Disease vaccine, adult dosage, for intramuscular use

90669* Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use

90675^ Rabies vaccine, for intramuscular use

90676^ Rabies vaccine, for intradermal use

90680* Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use

90690^ Typhoid vaccine, live, oral

2007 Louisiana Medicaid Professional Services Provider Training 100


Vaccine Codes

Code Description

90691^ Typhoid vaccine, Vi capsular polysaccharide (ViCPS), for intramuscular use

90692^ Typhoid vaccine, heat-and phenol-inactivated (H-P) for subcutaneous or intradermal use

90693 Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (US Military)

90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated, (DTaP-Hib-IPV), for intramuscular use

90700 * Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to younger than 7 years, for intramuscular use

90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use

90702* Diphtheria and tetanus toxoids (DT) absorbed when administered to younger than 7 years, for intramuscular use

90703 Tetanus toxoid adsorbed, for intramuscular use

90704 Mumps virus vaccine, live, for subcutaneous use

90705 Measles virus vaccine, live, for subcutaneous use

90706 Rubella virus vaccine, live, for subcutaneous use

90707* Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous

90708 Measles and rubella virus vaccine, live, for subcutaneous use

90710* Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

90712 Poliovirus vaccine, (any type(s)) (OPV), live, for oral use

90713* Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use

90714* Tetanus and diphtheria toxoids, (Td) absorbed, preservative free, when administered to 7 years or older, for intramuscular use

90715* Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to 7 years or older, for
intramuscular use

90716* Varicella virus vaccine, live, for subcutaneous use

90717 Yellow fever vaccine, live, for subcutaneous use

90718* Tetanus and diphtheria toxoids (Td) adsorbed when administered to7 years or older, for intramuscular use

90719 Diphtheria toxoid, for intramuscular use

90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use

90721* Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DTaP-Hib), for intramuscular use

90723* Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use

90725 Cholera vaccine for injectable use

90727 Plague vaccine, for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use

90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use

90734* Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for

2007 Louisiana Medicaid Professional Services Provider Training 101

Vaccine Codes

* indicates the vaccine is available from the Vaccines For Children (VFC) program

^ indicates the vaccine is payable for QMB Only and QMB Plus recipients


90735 Japanese Encephalitis Virus vaccine, for subcutaneous use

90736 Zoster (shingles) vaccine, live, for subcutaneous injection

90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use

90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use

90744* Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use

90746* Hepatitis B vaccine, adult dosage, for intramuscular use

90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use

90748* Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use



• Procedure code 90703 (Tetanus toxoid - for trauma) will be payable at the rate of $2.42, and it is not available through the VFC program.

• If the administration units for 90466, 90468, 90472 or 90474 are greater than the number of vaccines reported for the administration codes, the units will be cutback to reflect the number of vaccine codes being reported.

• If the administration units for 90466, 90468, 90472 or 90474 are less than the number of vaccines reported the claim will be processed based on the units listed for administration.



Healthcare provider taxonomy code set update


Background

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that covered entities use the standards adopted under this law for  lectronically transmitting certain health care transactions, including health care claims. The standards include implementation guides which dictate when and how data must be  sent,including specifying the code sets which must be used. The institutional and professional claim electronic standard implementation guides (X12 837-I and 837-P) each require use of valid codes contained in the HPTC set when there is a need to report provider type or physician, practitioner, or supplier specialty for a claim.

The National Uniform Claim Committee (NUCC) maintains the HPTC set for standardized classification of health care providers, and updates it twice a year with changes
effective

April 1 and October 1. These changes include the addition of a new code and addition of definitions to existing codes. You should note that:

1. Valid HPTCs are those that the NUCC has approved for current use;

2. Terminated codes are not approved for use after a specific date;

3. Newly approved codes are not approved for use prior to the effective date of the code set update in which each new code first appears; and

4. Specialty and/or provider type codes issued by any entity other than the NUCC are not valid.

CR 9461 implements the NUCC HPTC code set that is effective on April 1, 2016, and instructs MACs to obtain the most recent HPTC set and use it to update their internal HPTC tables and/or reference files. The HPTC set is available for view or for download from the Washington Publishing Company (WPC) at http://www.wpc-edi.com/
codes.

When reviewing the HPTC set online, you can identify revisions made since the last release by the color code:

*** New items are green;

*** Modified items are orange; and

*** Inactive items are red.

Hours and Days of Critical Care that May Be Billed


Critical care service is a time-based service provided on an hourly or fraction of an hour basis. Payment should not be restricted to a fixed number of hours, a fixed number of physicians, or a fixed number of days, on a per patient basis, for medically necessary critical care services. Time counted towards critical care services may be continuous or intermittent and aggregated in time increments (e.g., 50 minutes of continuous clock time or (5) 10 minute blocks of time spread over a given calendar date). Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient.
For Medicare Part B physician services paid under the physician fee schedule, critical care is not a service that is paid on a “shift” basis or a “per day” basis. Documentation may be requested for any claim to determine medical necessity. Examples of critical care billing that may require further review could include: claims from several physicians submitting multiple units of critical care for a single patient, and submitting claims for more than 12 hours of critical care time by a physician for one or more patients on the same given calendar date. Physicians assigned to a critical care unit (e.g., hospitalist, intensivist, etc.) may not report critical care for patients based on a ‘per shift” basis.

The CPT code 99291 is used to report the first 30 - 74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty. CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care (See table below). Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code such as subsequent hospital care.



Clinical Example of Correct Billing of Time:

A patient arrives in the emergency department in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code (CPT code 99291) and not also emergency department services. The cardiologist may report the 35 minutes of critical care services (also CPT code 99291) provided in the ED. Additional critical care services by the cardiologist in the CCU may be reported on the same calendar date using 99292 or another appropriate E/M code depending on the clock time involved.

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