By Delly Parham, CPC
Using locum tenens physicians to fill in for regular physicians may cost your practice instead of helping it if you don’t understand how to bill for their services. To ensure you get paid and stay in compliance, you must adhere to Medicare and commercial payer guidelines.
Practices usually use locum tenens (Latin for “lieutenant”) physicians when the regular physician is absent because of vacation, illness, childbirth, business, education, active duty, or having left the practice. The advantages of hiring a locum tenens physician versus using a physician in the same practice or in the same area are that it:
- Retains the regular physician’s existing patients
- Introduces new patients to the practice
- Maintains the patient level
- Keeps revenue with the regular physician
Most practices using the services of a locum tenens go through a recruiting agency, such as Comp Health. These companies handle the licensing requirements, professional liability insurance, and screening of the locum tenens, taking the liability and burden off practices. The practice or group pays the recruiting agency, and the agency pays the locum tenens physician. If your practice chooses to hire the locum tenens directly, you must:
- Check your state licensing laws for licensing requirements. Most – if not all – states require physicians be licensed in that state.
- Check with your professional liability insurance carrier.
- Make sure the locum tenens is in good standing and get his or her professional liability insurance certificate, verifying it covers the services the locum tenens will be performing for the regular physician.
Whether you use a recruiting agency or hire the locum tenens physician directly, the practice must:
- Train staff with information about locum tenens physician to retain patients with the regular physician and give them incentive to see locum tenens without fear, for example:
- The locum tenens is temporary and will only see them once or for a short period of time.
- The locum tenens’ experience and expertise as a physician.
The period for which a single locum tenens physician may substitute cannot be more than 60 continuous days. The 60-day period begins the first day the locum tenens physician provides services for Medicare patients of the regular physician. An exception to this 60-day rule is for regular physicians who are called to active duty in the armed forces. The time is unlimited. See Social Security Act at section 1842(b)(6)(D.)
The regular physician:
- Must schedule appointments under his or her schedule.
- Is the only physician who can break the locum tenens’ 60-day period.
- May re-set the 60-day period by returning to practice and see patients only one day after the initial 60-days and use the same locum tenens.
- Must bill for the services of the locum tenens.
- Must put his or her NPI number on all claims filed.
- May use more than one locum tenens to substitute for absences during the 60-day period.
- May reimburse the locum tenens a fixed amount per diem or similar fee for time.
- Must keep a record of each service furnished by the locum tenens physician and the NPI.
A locum tenens physician:
- Fills in for the regular physician for 60 continuous calendar days.
- Can substitute only if the regular physician is absent for any of the reasons above.
- Cannot substitute more than 60 continuous calendar days, unless there is a break in the 60-day by the regular physician.
- Cannot re-set the 60-day clock by taking a day off.
- Generally does not have a practice of his or her own and moves from area to area as needed.
- Is usually an independent contractor of the regular physician or group rather than an employee.
- Does not have to be enrolled in the Medicare program to see Medicare patients
- Cannot be a non-physician practitioner (e.g., NPs, CRNAs, PAs).
- Cannot bill Medicare for services within the 60-day continuous period in his or her name or NPI.
The regular physician bills and receives payment from Medicare and other payers who follow Medicare’s guidelines for the locum tenens physician’s services as though the regular physician performs the services. The regular physician must put the regular physician NPI in box 24J and his or her name in box 31 of CMS 1500 and the regular physician or group name and NPI in box 33 of the CMS 1500. Other Medicare rules include:
- Use the name and NPI of the regular physician or group.
- Use modifier Q6 after the procedure code (Q6 identifies services by locum tenens physician).
- If the only service a locum tenens physician performs is post-operative for an operation within a global period, it cannot be billed with Q6 modifier because the regular physician is paid a global fee, and it is not necessary to include the service on the claim.
- If a regular physician requires that the locum tenens physician provides services for longer than 60 continuous days without a break, the locum tenens physician must enroll with the practice.
Other payers have different rules. TRICARE requires that non-contracted locum tenens physicians complete a certificate or other document to be linked to the regular physician or group tax identification number. Some Medicaid programs (e.g., Florida Medicaid) require the locum tenens physician bill under his or her own name and NPI. Blue Cross Blue Shield adheres to the guidelines of Section 125b of the Social Security Act. (BCBS Manual for Physicians and Providers, May 2010).
Medicare Claims Processing manual, Chapter 1, Section 30:2.11, www.cms.hhs.gov/manuals/downloads/clm104
April 19th, 2013
Moving forward with implementation means your participation is vital.
If you thought the introduction of the electronic health record (EHR) would change coding, you were absolutely right. The days of sitting in the back office, appending ICD-9-CM codes to paper fee tickets and manually posting charges is, for some practices, in the distant past. Modern offices expect you to transform your coding knowledge into the fundamental tools used for EHR software development and compliance auditing. With a systematic plan, the right resources, and reasonably sophisticated EHR software, you can be a vital resource in their implementation.
Get Ahead of the Learning Curve
To participate in the development of compliant documentation templates, you must understand how an EHR is designed and how software is modified.
Overall, the EHR should interface with a billing or practice management software so patient demographics data attach to the medical record to avoid ‘wrong patient’ issues. Most EHR software is designed with pre-created templates used to capture patient medical data, document visits and procedures, order prescriptions, and document patient/provider communication—all seamlessly linked to the patient demographics. These templates are designed so providers can enter data through several methods. They can click check boxes or select radio buttons, and choose items from drop down menus to determine the information they want to document in the patient chart. The provider can type additional data within a text box, which displays this information exactly as it’s entered. Other patient data, such as chronic conditions, past medical history, and medication lists can be pre-loaded.
In some sophisticated software, templates can be set up to require some sort of action—almost like an internal email that alerts nursing staff to contact the patient regarding lab results. Other templates can be developed to order a prescription that automatically faxes to the pharmacy. These methods of selection and documentation are elements of a “user interface,” which is a behind-the-scenes mapping of how and where the information is displayed. Taking the time to learn about the behind-the-scenes default “language” that is all part of the EHR package’s user interface will help you determine whether there are options for clear and concise documentation, or if the documentation is limited to certain canned phrases and verbiage.
All EHR software arrives “out of the box” with default data lists that are used to populate the templates to drop pre-determined verbiage into a formatted document based on the provider’s selection. These data lists can include CPT® and ICD-9-CM codes, and place of service (POS) indicators, as well as more customized and editable lists such as office locations, special charges, and fee schedules. Data is typically selected through a drop-down menu.
In all cases, successful EHR implementation depends on the ability to understand, customize, test, and audit the capability and compliance of the EHR software. Coders, today, need to understand the concepts of a user interface, billing rules, and clinical documentation standards, and be able to translate coding and documentation guidelines for successful and compliant software development.
Test the EHR Before Going “Live”
A good software package will provide you with a test environment. When the practice decides to “go live” with a new EHR, there is a period during which the electronically-generated medical record should be systematically audited within a test environment to identify errors or bugs. These problems should be corrected prior to using the EHR in a “live” environment.
By comparing the computer generated notes against an approved audit tool, you can see where the software might be “double-dipping” (counting the same elements twice), pulling forward (bringing arbitrary documentation from another, unrelated note), or creating “bugs,” such as documenting both male and female system reviews for all patients. The completed EHR should meet all of the criteria for a legal medical document. This kind of testing is most effective if planned and implemented in a methodical manner, using test patients that you create, name, and run through the workflow process with varying visit types and medical scenarios.
Using a spreadsheet or database to capture and compare this analysis process is helpful, and can keep the project organized. Some scenarios to consider include:
- Are the templates for physical examinations age/sex appropriate?
- Are there opportunities to document all elements of the history of present illness (HPI)? The review of systems (ROS)?
- Are the examination templates set up to record based on 1997 or 1995 guidelines?
- Can your medical record be locked for security after a certain length of time? What is your addendum process?
- Can you import data such as lab results that are relevant to your current note? Is your note readable? Do consecutive notes appear to be copied, or cut and pasted?
- Do surgical/procedural templates allow for informed consent documentation?
- Is there space to document adverse effects or complications?
- Does your finger stick glucose lab template always default to a diabetes diagnosis? This should not be the case: Not everyone is diabetic!
- Does your wart destruction template allow for both benign and malignant lesion reporting?
Much of this developing and testing should be handled by your practice’s information technology (IT) department, but savvy coders, such as yourself, may want to develop super-user status. You can participate in pre-implementation activities, where you act as patients while the providers learn the software. During this time, make recommendations regarding coding compliance to the physicians, as well as the IT team.
EHR Software Works Best when Customized
The features that make an EHR easy to use, such as pre-filled templates, automatic code drop, and pre-determined diagnosis codes are the very things that cause compliance concerns. Think of the EHR as a tool that has to be sharpened and honed. It’s very effective if used correctly, but you have to learn how to use it safely, or you’re going to get hurt.
Most EHR software comes with pre-loaded E/M templates, which vendors probably will tell you are of the “plug and play” variety. Information systems experts and coders know that this is not necessarily the case. The Centers for Medicare & Medicaid Services (CMS) has not changed the E/M guidelines since 1997; however, the way the EHR captures data to support the levels of service has most definitely changed. Usually, the EHR configures the E/M templates in a manner similar to an audit tool, with a section for each of the key components: the chief complaint; HPI; ROS; past, family, and social history (PFSH); exam; and medical decision making (MDM). By working systematically, you and your IT staff can approach the development and customization of these templates in a way that ensures easy use and compliance within the final documentation.
Most EHR programs also have the capability to import documents. Scanning allows you to import a photo image of a document, to be stored in the patient’s chart. Establishing a direct interface between a lab or radiology department to import diagnostic results is a very efficient way to receive medical information into the patient chart. Having a consistent method of importing and cataloging these documents is important because it allows records to be easily identified and located at a later date. To meet compliance and patient care standards, all imported documentation must be reviewed and noted by the ordering physician before being stored in the electronic chart. Take it upon yourself to ensure that this is being done effectively and consistently.
Much of the custom work will be the IT department’s responsibility, with you acting as the compliance consultant. In smaller practice settings, your software vendor can be extremely helpful with the implementation process. Some EHR products offer users groups, which are online chat rooms offering a place for IT people, coders, and practice managers to post questions and discuss known issues. The bigger software companies provide seminars, conferences, and workshops on best-practice concepts and new initiatives. There is also an EHR discussion thread on the AAPC website where coders who are using the same EHR can “meet” and discuss.
Additional EHR Concerns to Address
Who Did What? Most EHRs have some “auditing” capability, where a behind-the-scenes look can identify which employee or clinician entered or edited which pieces of information. This allows you to see who is accessing the medical record (for instance, in case of privacy concerns), who is actually placing orders for medications and diagnostics, and where data entry errors might be occurring (to identify training opportunities). All EHRs should have signature and date recording ability for physicians and performing clinicians to meet the regulatory requirements of a legal medical record. This is one area where you can assist in workflow planning for compliance.
Procedure Templates: Most EHR software allows for easy documentation of office and surgical procedures. Templates should be designed to capture common elements of any given procedure, including anesthesia, informed consent, procedural elements, and follow-up instructions. When using these templates in a test environment, make sure the resulting procedure note makes sense, and your software default choices match the procedure that actually took place. For example, if your provider performs and documents a lesion excision, make sure your resulting note doesn’t document lesion destruction.
Annual Updates: Many of the EHR’s data lists, such as CPT® and ICD-9 codes, can be updated annually by the vendor, but often the vendor can provide only new codes. Frequently, the deleted and revised codes have to be edited individually and manually by you, or someone in IT, to ensure providers do not select invalid or deleted codes. One common issue in an EHR is that old diagnosis codes that are related to previous encounters remain in the patient’s list of chronic conditions, so the invalid codes can inadvertently be chosen again and again to appear on a claim form. Claim edits should be set up to prevent this from happening.
As you move forward with your implementation, other issues may present themselves. It’s critical for documentation compliance that you perform concurrent audits to review the EHR for completeness and accuracy as codes change, software is upgraded, and new providers begin to use the EHR. Having a comprehensive plan for EHR implementation that includes your participation in creating compliant EHR templates is essential. This implementation must include a comprehensive workflow evaluation to ensure that the EHR system your practice is using is configured in the best possible format as a legal medical record.
Pam Brooks, CPC, PCS, is physician services coding supervisor with Wentworth-Douglass Hospital in Dover, N.H.
April 4th, 2013
In small to midsized practices, failing to educate staff about correct coding may contribute to the practice’s downfall. Medical coding errors can be a huge source of lost revenue. A recent article in Physicians Practice reviews common billing and coding mistakes and offers suggestions on avoiding them. Several AAPC members were interviewed and quoted in the article as experts in the field, including Lynn Anderanin, CPC, CPC-I, COSC; Nancy Enos, CPC, CPMA, CPC-I, CEMC; Raemarie Jimenez, CPC, CPMA, CPPM, CPC-I, CANPC, CRHC; Debra Seyfried, CPC; and Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I.
The solutions offered include:
- Internal auditing
- Dedicating staff to following up on denials
- Verifying patients’ personal and insurance information
- Reviewing how to correctly use modifiers
- Teaching physicians what documentation is needed
- Learning the most recent code changes
Read the full article.
April 3rd, 2013
When submitting medical claims, not only do you need to get the codes right but you have to apply the right rules. AAPC’s Director of Product Development Raemarie Jimenez, CPC, CPMA, CPPM, CPC-I, CANPC, CRHC, recently published an article in Physicians Practice that reviewed how the rules vary between code book guidelines, payer preferences, and Medicare limitations.
“One of the biggest mistakes a practice can make is applying Medicare rules to all payers. This can cause improper reimbursement,” she says. “There are some procedures Medicare does not cover that private payers will and vice versa.”
Read the full article.
March 21st, 2013
By Ida Landry, MBA, CPC
Knowing coding and billing rules, and following them with integrity, is key to success.
Compliance is an important part of medical coding. Novice coders are instructed early on that “correct coding is the No. 1 objective,” and “if it isn’t documented, it wasn’t done.” These rules of thumb are the backbone of compliant coding for all coders. To be an effective coding compliance professional, however, you must also stay current with coding and billing regulations and have a solid code of ethics.
Know How Compliance Fits into Today’s Coding and Billing
Payment is generated or denied by the guidelines, rules, and federal laws payers use to direct their part of the revenue cycle. In the past, payers acted as compliance overseers, but in recent years legislation like the Tax Relief and Health Care Act of 2006 and the Affordable Care Act of 2010 have mandated more oversight regarding documentation and coding compliance. An example of the reimbursement climate resulting from these regulations is increased scrutiny by recovery audit contractors (RACs). “From 2005 through 2008, the Medicare RACs identified and corrected over $1 billion in improper payments. The majority, or 96 percent, of the improper payments were overpayments, while the remaining 4 percent were underpayments,” according to the Federal Register, 2011, p. 57808.
A byproduct of increased oversight is the establishment of more compliance departments and restructuring in health care organizations to meet the growing need for proper coding and documentation.
Key Compliance Principles
To understand fully coding compliance and be an effective medical coding compliance professional, you must have a commitment to the core principles, rules, guidelines, and laws that embody medical compliance. This is the first objective to successfully mastering compliance elements. Another important element is adhering to a code of ethics and integrity.
These core elements can be realized through successful instruction, education, and guidance of compliant coding and documentation requirements.
Compliance Means Trust, Not Opinion
As a coding compliance professional, you should provide tangible information whenever you instruct another health care professional on appropriateness of coding or documentation. If established guidelines, specifications, and/or legislation cannot provide validation, than any guidance given is considered opinion.
Protect trust at all cost. When an opinion is given as fact and later proven to be incorrect, this is unprofessional and risky. Once trust is broken, your opinion as a coding compliance professional is no longer credible. This guidance is simple; however, there are instances in the coding community where trust is destroyed.
Trust also is abused when a compliance professional tells a coder one thing and the health care provider something different. This behavior can stem from provider pressure or a provider’s inability to comply with rules and guidelines. To prevent inconsistent information from being disseminated, present the same guidelines, rules, and regulations to all parties involved. Using information consistently also shows ethics and integrity. To maintain consistency throughout an organization, consider following a code of ethics.
Code of Ethics
AAPC has a code of ethics which addresses coding professionalism and compliance integrity. The eight components of AAPC’s Code of Ethics are:
- Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.
- Respect the privacy of others and honor confidentiality.
- Strive to achieve the highest quality, effectiveness, and dignity in both the process and products of professional work.
- Advance the profession through continued professional development and education by acquiring and maintaining professional competence.
- Know and respect existing federal, state, and local laws, regulations, certifications, and licensing requirements applicable to professional work.
- Use only legal and ethical principles that reflect the profession’s core values, and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee.
- Accurately represent the credential(s) earned and the status of AAPC membership.
- Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests.
Other places to look for a code of ethics are your compliance or coding departments. Human Resource departments also may assist you if your company has a written code of ethics.
Use Compliance Tools at Your Fingertips
You can easily find useful tools to help you attain your goals. Here is a list of some typical resources you use:
- Office of Inspector General (OIG) website – On the “Compliance Guidelines” page, there are links to “Compliance 101 and Provider Education” and “Compliance Resource Material,” as well as other useful tools.
- Coding books - CPT® codebook, CPT® Assistant, ICD-9-CM, HCPCS Level II, AHA Coding Clinic for ICD-9, AHA Coding Clinic for HCPCS, OptumInsight’s™ Uniform Billing Editor, DRG Expert, and the AAPC website
- Government coding/billing resources – Centers for Medicare & Medicaid Services (CMS) manuals; National Coverage Determinations; Medlearn Matters; the Federal Register; 1995 and 1997 Documentation Guidelines for Evaluation and Management Services; Medicare administrative contractors, Local Coverage Determinations, etc.
- Freedom of Information Act – Used to request federal agency records not publicly available.
- Federal acts - Health Insurance Portability and Accountability Act (HIPAA); Health Information Technology for Economic and Clinical Health (HITECH) Act; the Affordable Care Act; Tax Relief and Health Care Act of 2006; False Claims Act; Medicare Prescription Drug, Improvement, and Modernization Act of 2003; Stark law; anti-kickback statute, etc.
- Commercial payer resources – Look to company manuals, websites, webinars, and newsletters for guidance.
- Company compliance manuals – Your employer should be anxious to share its compliance manuals and plans with coding and billing staff.
Being a coding compliance professional is a noble profession with ethics and integrity, knowledge of documentation and coding guidelines, and trust and validation at the core of its foundation. If you think you have what it takes to be a coding compliance professional or are thinking about becoming certified, AAPC now offers the Certified Professional Compliance Officer (CPCO™) credential. Go to aapc.com for details on how to begin this exciting journey.
Ida Landry, MBA, CPC, works for CareOregon and has worked in the health care industry since 1995. She acquired CPC® certification in 2004. Ms. Landry holds a Bachelor of Science in Health Administration and a Master of Business Administration in Health Care Management. She enjoys teaching and sharing her knowledge of coding.
March 1st, 2013