Neurosurgery Coding Alert

Obtaining reimbursement from Medicare for procedures performed by substitute neurosurgeons can be tricky because of confusion regarding use of the appropriate modifiers and the billing options available. It is essential to understand the choices, which include reciprocal billing, billing for each service separately, and locum tenens.

Options for Substitutes

Neurosurgeons temporarily unable to care for their patients have three billing options:

Enter into a reciprocal billing arrangement with one or more neurosurgeons,whereby the substituting physician performs the service but the original doctor bills for it;

Provide services to each others patients and bill for each service or procedure performed under ones own provider number; or

If the neurosurgeon is going to be unavailable for an extended period, or has left the practice, or cannot reciprocate coverage, a locum tenens physician can perform the service, which is billed under the absent doctor's provider number.

The advantage of the first option reciprocal billing is that the neurosurgeon who is unavailable still gets paid, even while away. For the substituting neurosurgeon, the benefit is that a new billing account does not need to be opened for a patient who is unlikely to visit again because he will probably return to his regular physician.

The reciprocal billing guidelines in CPT 2001 state: In the instance where a physician is on call for or covering for another, the patients encounter will be classified as it would have been by the doctor who is not available. For example, even though this may be the first time the substitute neurosurgeon is meeting with this patient, it is not categorized as a new patient visit (99201-99205) or as a consultation (99241-99245), but is an established patient visit (99211-99215). This is because the second doctor has access to the patients medical record from the originating neurosurgeon and does not need to complete a full history and physical.

Reciprocal coverage is used when a physician is ill or on vacation, says Cynthia Thompson, CPC, a coding and reimbursement specialist with Gates, Moore and Co., an Atlanta consulting firm. For example, it might be used when a neurosurgeon undergoes surgery personally and is unable to work, but not long enough so that he or she wants to bring in a locum tenens, Thompson says.

Note: Locum tenens refers to retaining substitute physicians to temporarily take over professional practices in the absence of the regular physician (up to 60 continuous days) for reasons such as illness, pregnancy, vacation, or continuing medical education. If the regular physician returns to practice for even a single day, the 60-day period begins again. The regular physician bills and receives payment for the substitute doctor's services as though he/she performed them. The [...]