ASGE members may submit coding inquiries electronically to codingquestions@ASGE.org. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Below are two questions that could be beneficial to your practice.
Question #1
Can we use a locum to cover for physician vacations and bill under the physician with Q6 modifier? We lost a physician in one of our offices, so when one of the physicians is on vacation, we only have one physician in the clinic and endoscopy center, which is causing a backlog of work. We want to make sure this was an appropriate use of a locum before we did this.
Answer
Locum tenens now is found under FFS (fee-for-service) for Centers for Medicare and Medicaid Services (CMS). Here is some information:
FFS Time Compensation Criteria
FFS time compensation applies when there is a regular physician or physical therapist’s absence for reasons such as:
- Illness
- Pregnancy
- Vacation
- Continuing medical education
- When the regular physician or physical therapist leaves the practice
A regular physician may include a physician specialist such as a:
- Cardiologist
- Oncologist
- Urologist
- Hospitalist
- Radiologist
- Pathologist
Length of Time
Medicare covers the substitute physician services for 60 days at a time. After the 60 days, a regular physician may hire another substitute physician.
If a physician dies, then Medicare does not allow FFS time compensation. Medicare deactivates the provider enrollment record for the deceased physician on the date of death.
Remember to follow the provider enrollment requirements for updating records. This may limit using a substitute physician to 30 or 90 days.
View 42 CFR Section 424.516 Section (d) for the provider enrollment requirements.
FFS Time Compensation Documentation
The regular physician maintains the documentation. All documentation principles apply to the substitute physician services.
The documentation must show:
- The regular physician is not available to perform the service
- The patient arranges to see the regular physician
- The substitute physician’s signature as the performing provider
- The substitute physician’s National Provider Identifier (NPI)
FFS Time Compensation Claims
The absent physician bills and receives payment for the substitute physician’s services as though he or she performed them. Include the following on the claim:
- The regular physician’s NPI on the CMS claim form item 24J or electronic equivalent
- Modifier Q6 on the claim line item
Question #2
When an ERCP sphincteroplasty, CPT code 43277, is performed due to a stone (not a stricture), blocking access to complete a balloon sweep of the same duct, CPT code 43264, is the sphincterotomy CPT code 43277 billable separately or can CPT code 43277 only be reported with CPT code 43264 when a stricture, specifically, is present?
Answer
Per CPT code, 43277 may be reported if sphincteroplasty or dilation of a ductal stricture is required before proceeding to remove stones/debris from the duct during the same session. Dilation that is incidental to the passage of an instrument to clear stones or debris is not reported separately.