Sunday, March 20, 2011

Updates from the CMS front.... timely filing, GZ mod, Home Health certification

Just some quick info that you might need to know.....

 On March 23, 2010, President Obama signed into law the Patient
Protection and Affordable Care Act (PPACA), which amended the
time period for filing Medicare fee-for-service (FFS) claims.

 The Timely Limit to file claims was reduced to one year for the date of
service. (i.e. if the DOS was June 8, 2010, the claim must be filed by
June 8, of 2011.)

 Additional information can be found in MLN Matters article MM6960.



Auto denial of claim line(s) items submitted with a GZ Modifier

This Change Request requires that, effective for dates of service on and after July 1, 2011, all Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractors (RACs), Program Safeguard Contractors (PSCs) and ZPICs Zone Program Integrity Contractors (ZPICs) must automatically deny claim line(s) items submitted with a GZ modifier.

Contractors should not perform complex medical review on claim line(s) items submitted with the GZ modifier.

The GZ modifier indicates that an Advance Beneficiary Notice of Non-coverage (ABN) was not issued to the beneficiary and signifies that the provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy.

All MACs must make all language published in educational outreach materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ modifier must be denied automatically and will not be subject to complex medical review.

Medicare Claims Processing Manual, Pub. 100-04, Transmittal No. 2148, February 4, 2011 and Program Integrity Manual, Pub. 100-08, Transmittal No. 366, February 4, 2011.



A new Medicare home health law went in to effect on January 1st, 2011 that affirms the role of the physician as the person who orders home health care based on personal examination of the patient. Effective in January, a physician who certifies a patient as eligible for Medicare home health services must see the patient. The law also allows the requirement to be satisfied if a non-physician practitioner (NPP) sees the patient, when the NPP is working for or in collaboration with the physician.

As part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and document how the patient’s clinical condition supports a homebound status and need for skilled services. The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care.

While the long-standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition. In situations when a physician orders home health care for the patient based on a new condition that was not evident during a recent visit, the certifying physician or NPP must see the patient within 30 days after admission.

The new requirement includes several features to accommodate physician practice. In addition to allowing NPPs to conduct the face-to-face encounter, Medicare allow a physician who attended to the patient but does not follow patient in the community, such as a hospitalist, to certify the need for home health care based on their face to face contact with the patient in the hospital and establish and sign the plan of care. Medicare will also allow such physicians to certify the need for home health care based on their face to face contact with the patient, initiate the orders for home health services, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care. Finally, in rural areas, the law allows the face-to-face encounter to occur via tele-health, in an approved originating site.

Certification and Recertification of Home Health Services

G0180 - Physician services for the initial certification of Medicare- covered home health services, for a patient's home health certification period

G0179 - Physician services for the recertification of Medicare-covered home health services, for a patient's home health certification period

These two codes are used to report the work involved in new certification and recertification paperwork

Keep in mind-These codes can not be used in the Medicare rural health care clinics as they do not meet the requirements of a face to face visit unless done at the time of the face to face visit.

Reciprocal billing/Locum Tenens: Q5 or Q6? What a coder needs to know.

The term “locum tenens” is Latin for “to hold the place of”. In the medical profession, this means a provider who essentially ‘fills in’ for a provider who is temporarily absent from their practice.

In the medical profession, it is not uncommon for physicians to hire a substitute or ‘locum’ to take over their practice when they are absent for an extended period of time. These substitute physicians usually do not have a practice of their own, and move from job to job as a ‘permanent’ temporary employee.

A coder needs to understand the rules of locum tenens billing and reciprocal billing arrangements. This understanding is crucial to keeping the revenue flow in the practice smooth, and not interrupted by unpaid or denied claims by CMS or your private insurance payers. Medicare has put forth some guidelines regarding billing of claims in these circumstances. The HCPCS modifiers Q5 and Q6 are designated for locum tenens usage and reciprocal billing arrangements.

HCPCS Modifier Q6 - Payment Under Locum Tenens Arrangement

The usage of modifier Q6 was developed by CMS specifically to address billing concerns when a physician is away from their regular practice. (i.e. for vacation, illness, education, etc).

To help solve this issue, the Q6 modifier designation informs Medicare, that a ‘locum’ has stepped into the practice, on a temporary basis, to provide continuation of medical care.

The locum tenans guidelines only apply to providers such as MD’s and DO’s. Locum tenens does not apply to providers such as Physical Therapists, or Nurse Anesthetists. If a coder is unsure to bill locum tenans for a Nurse practitioner (NP) , Physician Assistant (PA) , or Certified Nurse Midwife (CNM), they should check with their local Medicare carrier for clarification of the modifier Q6 and if it is appropriate for these provider types. At this time, the CMS guidelines only state locum billing in relation to MD’s and DO’s.

CMS allows a locum to provide services for a maxium of 60 continuous days for the absentee physician. CMS does not specifically state how long a ‘break’ there needs to be in between the continuous 60 day time limit. If you know that your physician is going to be out for more than 60 days, an alternative plan for physician coverage and patient care would need to be made.

HCPCS Modifier Q5 - Service Provided by a Substitute Physician Under a Reciprocal Billing Arrangement

The usage of modifier Q5 is to be used only for a reciprocal billing arrangement, and noted on the CMS 1500 claim form. The reciprocity billing arrangement comes into play, when one physician covers for another, then provides care for those patients, who are normally cared for by physicians within the same practice or group practice. i.e. Physician “A” is providing coverage for Physician “B”, while Physician “B” is out of the office.

In the scenario above, the covering physician must be a permanent part of the existing office practice, and is not hired from the outside, or operating under a different tax ID number, or billing for services provided under a ‘group practice’ tax ID number.. Again, CMS limits this to 60 continuous calendar days where a reciprocal billing agreement is in effect.

Basic rules of billing for a locum tenes or reciprocal billing physician:

  1. Use the Q5 or Q6 modifier in box 24d of the CMS-1500 form for each line item in the claim. (append the modifier for each line item service)

  2. Enter the regular physician's NPI in box 24k of the CMS-1500 form.

  3. Add the NPI and name of the “locum” or “reciprocal” physician in the ‘notes” line of the CMS 1500 form (not mandatory, but helpful)

  4. Keep track of the locum's NPI and his/her services in your files in case your carrier requests them.

  5. Keep track of the calendar dates the locum was providing these services in case your carrier requests this information.

Coders need to keep in mind that ‘locum tenens’ billing was created for usage by CMS, for physicians that are providing services under the Medicare payment system. Private insurance payers may not recognize services provided by a locum or reciprocal billing agreements. It is wise to contact those insurance payers ahead of time (if possible) to determine what course of action you should take for submitting your claims while your physician is absent from the practice.