After hours coding? Here’s a word of caution: You can’t catch ER coverage services with after-hours codes. If you bill the wrong way when your physician covers for others — or for that matter when another physician covers for your physician — you could be setting yourself up for charges of fraud.
Avoid the hassle: Keeping in mind these few simple answers to the top three on-call billing questions will help you correctly file claims.
1. Which doctor bills for the services?
If your physician is on call and handling patient services for another physician, don’t make the mistake of letting the other physician bill for the services. Although a patient sees a particular physician, that does not imply that the physician can bill for any services related to that patient’s care. When your physician provides a service, you should bill the services even if your physician is on call for another doctor.
Bobbi M. Bohon, CPC, of Seven Hills Surgical in Lynchburg, Va, says, “I bill for those billable visits when my surgeon is on call and covering for the other surgeons in town.”
Verify the NPI: Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio, suggests “Each doctor who sees a patient should bill for the appropriate services rendered under his/her own NPI (National Provider Identifier) number.”
Hint: Bohon says, “The physician who sees the patient face to face and documents and signs his/her name should bill for those services provided regardless of who the admitting surgeon is.”
2. How to report on-call ER services?
Many times, physicians tend to patients in the emergency department while on call. Don’t run for the after-hours codes to bill these services when the hospital pays your physician for being on-call.
Reason behind: You cannot bill twice for the physician’s services if the hospital is already paying him to be on-call physician in the emergency room (ER). You should bill the after-hours codes 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally shut [e.g., holidays, Saturday or Sunday], in addition to basic service) and 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) only when your physician sees a patient in your office outside regular office hours and another third party is not compensating him for his time, suggests Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.
For instance: If your office closes at 5 p.m. but your physician sees a patient on an emergency basis at 7 p.m., you should report 99050 in addition to any other services provided. You should not report 99050 if your physician saw the patient in the emergency room at 7 p.m.
3. Can billing be skipped altogether?
You may be desirous to simply arrange a substitute arrangement with other practices for your physicians to cover for one another at various times. This, however, sets your practice up for financial liability and lost reimbursement. “Reciprocal billing” works only for two practices that have similar size practices with similar patient and similar acuity and whose doctors perform nearly equal coverage.
Reason behind: This type of arrangement saves on paperwork, but it isn’t realistic to assume that the workloads between the physicians will all even out over time. One physician might end up with a very time-consuming patient to deal with. So assuming that the inequities will all balance out in the end just doesn’t work. Each physician should bill for the work he performs.
Hint: Lamm says, “You may desire to have a healthcare attorney to review your on-call billing arrangements to ensure that you’re not fraudulently reporting services.” However Medicare does recognize “reciprocal billing” and even has a modifier to indicate when you are participating in reciprocal billing. You can use modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement) to indicate to your Medicare carriers that you’re participating in a reciprocal billing arrangement, Cobuzzi says. Private payers, on the other hand, don’t require a modifier when you’re doing reciprocal billing.
Important: Cobuzzi concludes, “Remember that by using the Q5 modifier, you are telling Medicare that the billing physician is not the actual rendering physician, as without a modifier, a private payer who has not given you a sanction in writing for reciprocal billing may interpret it as billing for services that were not provided.”
