ED Coding and Reimbursement Alert

Question: I have residents who moonlight for us in the emergency department. Do they fall under the regular teaching physician rules or can they bill independently?

Kansas Subscriber

Answer: CMS rules allow a resident to moonlight at an ED site that is not a part of their training program. As long as the resident is properly licensed, credentialed, and carries the appropriate malpractice insurance coverage, the site may bill for their services. CMS requires the physician rendering the service to be identified on the claim, whether the rendering physician receives the payment directly or assigns the right to payment to another physician or entity. The moonlighting resident's PIN must be listed in box 24k of the claim form, while the PIN for the physician or group to which residents assign their right to payment must appear in box 33.

Moonlighting residents can reassign to an employer the right to payment for Medicare-covered services only if they are eligible to receive the payment. A moonlighting resident must complete the Medicare application process and receive a UPIN and a PIN to be allowed to reassign the right to payment to an employer.

If the Moonlighting arrangement falls under locum tenens rules, Medicare requires you to indicate this with modifier Q6 (Service furnished by a locum tenens physician). Private payers have no equivalent billing modifier, but you might still want to use Q6 and its guidelines to protect your arrangements. If you are audited and the auditor questions why you are billing patients your physician did not see, you can explain that you indicated this with modifier Q6 as Medicare requires and accepts. Just make sure you adhere to the following guidelines.

Under locum tenens arrangement, your group or facility would pay the moonlighting resident for services provided on a per-diem or similar fee-for-time basis. Bill the service under the group's national provider identifier (NPI) as you normally would. To indicate a substitute physician is actually providing these services, append modifier Q6 to the CPT^® codes, such as 99281-99283 (Emergency Department Services). Also, list the ED group physician's NPI for whom the substitution services are furnished in item 24k on the CMS-1500 claim form or electronic equivalent. This requirement implies that the resident has enrolled in Medicare and received an NPI.

If required make sure you also meet these Medicare locum tenens documentation requirements:

1. The substitute physician's services may not continue beyond a continuous period of 60 days.
2. The group must retain a copy of each service the substitute physician provides, along with the substitute physician's NPI number.

Beware: Locum tenens arrangements are one-way exchanges as your description indicates. Reciprocal billing arrangements involve two physicians alternating services, such as weeks or weekends off, and fall under modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement).

For more information on reciprocal billing and locum tenens arrangements, see the Internet-Only Manual 100-04, Chapter 1, 30.2.10-11, available at the CMS Web site.