Coding Strategy

Before using modifier Q6 for a non-Medicare patient, check with the commercial payer — here’s why.

Question: We hired a locum tenens for two weeks. Do we code the same for the replacement physician as for a full-time oncologist?

Georgia Subscriber

Answer: Private payer rules may vary, but for Medicare patients, you should append modifier Q6 (Service furnished by a locum tenens physician) to each procedure code on the temporary doctor’s Medicare claims. You should bill under the national provider identifier (NPI) of the physician the locum is replacing.

Although your two-week arrangement falls well inside Medicare’s 60-day limit for a locum tenens physician, you should be aware that a substitute physician may not provide services to Medicare patients for more than 60 days, according to the Medicare Claims Processing Manual, Chapter 1, Section 30.2.11. (See additional details in the manual, online at www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.)

Private payers vary: Before using modifier Q6 for a non-Medicare patient, check with the commercial payer. Some will follow the Medicare locum tenens guidelines, but you should not assume that all commercial payers will want modifier Q6. Private payers’ rules regarding substitute physicians can differ from Medicare’s.

Definition: A locum tenens arrangement describes a one-way exchange between physicians, in which your oncologist or hematologist retains a substitute physician (the locum tenens) to take over the practice temporarily and pays the substitute physician a fixed amount per diem or similar fee-for-time structure. Reasons for hiring a locum tenens may include the regular physician needing time away for illness, pregnancy, vacation, or continuing medical education.

@ Oncology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

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Have your documentation ready for reporting level P4 and higher.

Physical status modifiers, also referred to as P modifiers, PS modifiers, ASAs or ASA P codes, are an important element of your anesthesia coding. If you don’t use them correctly, you could dash your reimbursement opportunities, or risk a payer audit.

Skip P Modifiers With Medicare, But Check Private Payers

If your anesthesiologist works with a number of Medicare patients, you probably haven’t spent much time learning the finer points of anesthesia’s Physical Status Modifiers. Why? Because Medicare does not pay for them.

End of story, right? Not if your practice contracts with private payers. Many private payers will often reimburse for P modifiers if you follow the guidelines.

“Reporting is dependent on the carrier and can be dependent on whether the group negotiated for it in their contract. Most government payers do not allow reporting or payment of PS modifiers,” says Debbie Farmer, CPC, ACS-AN, coder with Auditing for Compliance & Education in Leawood, Kan.

Example: A 2001 Aetna anesthesia policies memo states, “When these modifiers/codes are reported, additional ASA units may be allowed and combined with the base unit value for the anesthesia service performed.” While the trick is in meeting those conditions, you don’t have to shy away from P modifiers if you know the basics.

Use 6 Levels to Define Patient’s Status

The American Society of Anesthesiologists (ASA) developed physical status modifiers to allow coders to distinguish between different levels of complexity of anesthesia service. These levels are based on the patient’s condition, as follows:

• P1 — Normal healthy patient
• P2 — Patient with mild systemic disease
• P3 — Patient with moderate systemic disease which can be a threat to life
• P4 — Patient with severe systemic disease that is a constant threat to life
• P5 — Moribund patient who is not expected to survive with or without the operation
• P6 — Declared brain-dead patient whose organs are being removed for donor purposes.

The ASA does not provide concrete definitions for physical status modifiers because their use is based on clinical decisions the anesthesia provider makes for each patient.

Hint: Most of your anesthesiologist’s services require a P1, P2, or P3 modifier. To use P4 or higher, you need clear documentation in the medical record to support its use. Even if your anesthesiologist classifies a patient as P3, many payers will want more information to support the claim.

How it works: A patient with stable angina would be considered a P3 status. This patient has a systemic disease that could kill him, but he is stable and expected to do well.

A patient with a P4 status has his life constantly threatened by his disease. “ASA 4’s are patients who are not expected to die in the perioperative period, although it wouldn’t be totally unexpected if they do,” says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. Someone with unstable angina, or in congestive heart failure who needs surgery, would be a 4.

Make Sure You Clarify Dx and Documentation

In its “Revised Hospital Anesthesia Services Interpretive Guidelines,” CMS offers clarification on minimum accepted standards of what should be included in a pre-anesthesia evaluation of a patient, including “notation of anesthesia risk according to established standards of practice (e.g. ASA classification of risk).”

Why it’s important: The preop note should regularly include PS classification, Groudine says. If it doesn’t, your practice may not be complying with CMS rules.

The best way to ensure you’re using the proper PS code is to check, and double-check, your physician’s documentation. In many cases you can find the ASA classification included in the operating room nurse’s notes.

Heads up: “Many times I see that a claim went in without a diagnosis to support the underlying condition for reporting the PS modifier and the carrier will not allow the additional unit,” Farmer says.

Note: You cannot use a PS code with an add-on code such as +01953 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; each additional 9% total body surface area or part thereof).

@ Anesthesia Coding Alert, Joshua Thines

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The answer hinges on the urologist’s interpretation.

Question: A patient had a robotic prostatectomy for prostate cancer on Jan. 1. Then the patient started experiencing voiding problems in February. At that time my doctor did a cystoscopy to check for bladder neck contracture, which he didn’t find. Is this a new problem? How should I code the second procedure?

Virginia Subscriber

Answer: You’ll have to discuss the procedure with your urologist to see if he considers the voiding dysfunction to be a new problem or a complication of the radical surgery.

Option 1: If the voiding trouble is a new problem, you should report the cystoscopy within the global of the radical prostatectomy using modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). So you will report 52000-79 (Cystourethroscopy [separate procedure]) for both Medicare and commercial payers. The diagnostic code should represent the symptom(s) that led to the cystoscopic examination.

Option 2: If your urologist feels that the problem with voiding is a complication of the surgery, your coding will depend on the payer and the location where the cystoscopic examination took place.

If the patient has Medicare coverage and your urologist performed the cystoscopy in the hospital operating room, then bill the cystoscopy with modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period). If this Medicare patient underwent the cystoscopic examination in the office, most Medicare carriers would not reimburse for this procedure.

For private payers, bill for an in-office cystoscopy with modifier 79 as mentioned above, even if you feel this is a complication. Most commercial and private payers will reimburse for the procedure performed in the global of the radical prostatectomy, and will pay (no matter the location) for any problems after surgery that prevent a smooth uncomplicated surgical convalescence and postoperative care.

@ Urology Coding Alert

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Medicare’s elimination of payment for consultation services has caused mass confusion throughout the coding community, not just due to the changes it has caused in your billing procedures, but also due to lack of information from CMS.

In an apparent attempt to quell those issues, CMS has released MLN Matters article SE1010, which offers several questions and answers regarding how to report your services now that Medicare no longer recognizes consult codes (99241-99255).

For example, CMS addresses the often-asked question of whether the agency will release a crosswalk of  consult codes to E/M codes. “No,” CMS responded in the article. “Providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished.” In other words …

You must report the E/M code that best matches your provider’s documentation, rather than attempting to find the appropriate consult code and matching it to an office or hospital visit code.

Plus: Many providers have been concerned about what will happen if  they report a subsequent hospital care code (99231-99233) for a physician who hasn’t first billed an initial hospital care code (99221-99223).

CMS responds that it has instructed MACs “to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met,” even if that provider is seeing that patient for the first time during his or her hospital stay.

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Include this term in Box 19 to indicate the type of implant.

Question: One of our surgeons says we should use a total hip code for Birmingham resurfacing even if he doesn’t complete a total hip procedure; another physician says to use an unlisted code . What’s the correct answer?

Washington Subscriber

Answer: Both of your physicians could be right depending on the situation, so check with the payer before submitting your claim following one of these options:

• Report 27125 (Hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty]) or 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip arthroplasty], with or without autograft or allograft) based on whether the surgeon places an acetabular component.
• Report 27299 (Unlisted procedure, pelvis or hip joint) and compare to _______ for reimbursement purposes.
• Some private payers such as Blue Cross/Blue Shield request S2118 (Metal-on-metal total hip resurfacing, including acetabular and femoral components) for hip resurfacing instead of the CPT codes.

Once you select a code, include “Birmingham” in Box 19 to notify the payer of the type of implant used.

@ Orthopedic Coding Alert

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