(Medicare Claims Processing Manual)

A/B MACs Part B should inform physicians and physical therapists of the compliance requirements when billing for services of a substitute physician or physical therapist. The physician/physical therapist notification should state that, in entering the Q6 m odifier, the regular physician or physical therapist (or the medical group or physical therapy group, where applicable) is certifying that the services are covered visit services furnished by the substitute physician or physical therapist identified in a r ecord of the regular physician or physical therapist which is available for inspection, and are services for which the regular physician or physical therapist (or group) is entitled to submit the claim.  A/B MACs Part B should include in the notice that pe nalty for false certifications may include civil or criminal penalties for fraud, or administrative penalties including revocation of the physicians or physical therapists Medicare billing privileges, right to receive payment, or to submit claims or acce pt any assignments.  The revocation procedures are set forth under 42 CFR  424.535 and in the Medicare Program Integrity Manual (Pub. 100- 8).  If a line item includes the code Q6 certification, A/B MACs Part B assume that the claim meets the requirements of this section in the absence of evidence to the contrary.  A/B MACs Part B need not track the 60- day period or validate the billing arrangement on a prepayment basis, absent postpayment findings that indicate that the Q6 certifications by a particular regular physician or physical therapist may not be valid.  When A/B MACs Part B make Part B payment under this section, they determine the payment amount as though the regular physician or physical therapist provided the services.  The identification of the substitute physician or physical therapist is primarily for purposes of providing documentation to verify upon audit that the services were furnished, not for purposes of the payment or the limiting charge.  Also, notices of noncoverage are to be given in the name of the regular physician or physical therapist.   C.  Requirements applicable to Physician Medical Group or Physical Therapy Group Claims Under Fee- For-Time Compensation Arrangements   In order for a medical group or physical therapy group to submit claims in the name of the regular physician or physical therapist for the services of a substitute physician or physical therapist, the substitute physician or physical therapist may not have  reassigned his or her right to Medicare payment to the group through a CMS -855R reassignment enrollment form approved by the A/B MACs Part B and the following requirements must be met:    The regular physician or physical therapist is unavailable to provide the services;     The Medicare patient has arranged or seeks to receive the services from the regular physician or physical therapist; and    The substitute physician or physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days subject to the following exception: A physician or physical therapist called to active duty in the Armed Forces may bill for services furnished under a fee -for-time compensation arrangement for longer than the 60- day limit.   For purposes of these requirements, per diem or similar fee -for-time compensation which the group pays the substitute is considered paid by the regular physician or physical therapist.  Also, a physician or physical therapist who has left the group and for  whom the group has engaged a substitute as a temporary replacement may bill for the temporary physician or physical therapist for up to 60 days.  The term regular physician or physical therapist includes a physician or physical therapist who has left the group and for whom the group has hired the substitute as a replacement.    Services are billed for the entity as follows:   The medical group or physical therapy group must enter in item 24d of Form CMS -1500 the HCPCS code modifier Q6 after the procedure code.    The designated attending physician for a hospice patient (receiving services related to a terminal illness) bills the Q6 modifier in item 24 of Form CMS -1500 when another group member covers for the attending physician.   A record of each service provided by the substitute physician or physical therapist must be kept on file along with the substitute physicians or physical therapists NPI.  This record must be made available to the A/B MACs Part B upon request.   In addition, the medical group physician or group physical therapist on whose behalf the services were furnished by a substitute must be identified by his/her NPI in block 24J of the appropriate line item.   30.2.12 - Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims  (Rev. 1, 10- 01-03) B3-3060.8  Any person or entity wishing to receive Part B payment as a reassignee  of one or more physicians (or other practitioner or supplier), or as the supplier of the services, must furnish to the carrier sufficient information to establish clearly that it qualifies to receive payment for those services.  Where there is any doubt t hat the person or entity qualifies, the carrier must obtain additional evidence.   In some cases, an entity may qualify to receive payment for the services of a physician on the basis of one or more of the exceptions listed in 30.2.  As soon as it is determined that an organization can qualify on any basis, no further development may be needed for that physician or for other physicians having the same status. However, where some other physicians have or appear to have different stat us, further development is required.  In some cases a determination is made that Part B payment can be made only to the physician.  Subject to the provisions of 30, a reassignee assumes liability for any overpayments that it receives and should be so advised.   A.  Payment to Special Accounts   Sometimes a major institution, such as a medical school or university, may want the Medicare checks due it for physician services to go into particular specialty accounts (or funds, or so- called group practices) which are subdivisions of the institution, a nd may ask that these accounts be identified on their Medicare checks for internal accounting purposes.   Ideally, to indicate the subordinate nature of the account in relation to the institution, carriers list the name of the institution first on the check, followed by the name of the appropriate account.  However, identifying the payee in this manner may cause serious claims processing difficulties, fostering confusion between various accounts of the same institution.  To avoid this problem, carriers may list the name of the account first, followed by the name of the institution, e.g., Radiology Fund or Gener al Medical Center, if the institution submits a letter accepting responsibility for any claims submitted, and payments made, under the special designations.  The letter needs to describe the special designations the institution wants on the checks for the various accounts and include a statement to the following effect:  The (name of institution) accepts the same responsibility for the Medicare claims and payments made under these special designations as it would have if the payments were made by Medicare in the name of (name of institution) without these special designations.  This statement is required in addition to the statement the institution submits to establish its right to receive payment for the physicians services.  If the above procedure is used as a basis for Part B payments in the names of departments, specialties, or similar subdivisions of a university or medical school or an associated nonprofit foundation or teaching hospital, each subdivision may also execute, or refrain from executing, a participation agreement for physician services in that subdivision.  This is an exception to the rule that a participation agreement may only be executed by a person or legal entity.  This exception applies only in the medical school or university medical center context.  30.2.13 - Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for A/B MAC Part B Processed Claims  (Rev.  3774, 05-12-17, Effective: 06-13-17, Implementation: 06-13-17)  Except where otherwise noted, the following procedures apply to both assigned and unassigned claims submitted by medical groups and other entities entitled to bill and receive payment for physician services under 30.2-30.2.8.  They are used whether the charges are compensation related or non- compensation related.   A General   Chapter 26 contains general claims processing instructions. A medical group, or other entity entitled to bill and receive payment for physician services uses the current ASC X12 professional claim billing format or Form CMS-1500 to submit claims to Medicare A/B MACs Part B .  A single claim form may contain services furnished to the same patient by different physicians associated with the same entity.  The name and address of the entity is entered in block 33 of Form CMS-1500 or in the corresponding ASC X12 837 location. For paper claims an authorized official of the entity signs in block 31.  This official need not be a physician.  For electronic claims a certification can be maintained on file. (See CMS EDI Web page ( http://www.cms.hhs.gov/providers/edi/edi3.asp) for electronic billing formats.)   B Provider Identification Numbers   The entitys NPI, when required, is entered in block 33a.  Each physician who performs services for a patient must be identified on the Form CMS -1500 claim in block 24J for the appropriate line item in accordance with instructions in the Medicare Program Integrity Manual.  (When an entity bills for an independent substitute physician or physical therapist  under a reciprocal or fee- for-time compensation substitute billing arrangement, the performing physician  or physical therapist  identified on the claim form is the regular physician or regular  physical therapist  who is a member of the entity.)   C Payment Records   Where the charges by a hospital, medical group, or other entity differ depending on the individual treating physician, A/B MACs Part B transmit the performing physicians   NPI when required on the Common Working File (CWF) claim record.  Where the charges  by a hospital, medical group, or other entity are uniform regardless of the individual performing physician, claims records are prepared by entity and entity identification numbers rather than by individual physician and individual physician identificatio n numbers.  Show code 70 as specialty code on claims records where such entitys physicians have mixed (more than one) specialties.  Where all the physicians associated with such entity have the same specialty, the code used reflects the specialty, e.g., c ode 30 for a group of radiologists, code 11 for a group of internists.  D Outpatient Physical Therapy or Speech -Language Pathology Claims  Clinics that have been certified to provide outpatient physical therapy or speech- language pathology services to outpatients also use the ASC X12 837 professional claim format, or the CMS -1500 claim form for billing the A/B MAC Part B .  30.2.14 - Correcting Unacceptable Payment Arrangements  (Rev.  3774, 05- 12-17, Effective: 06- 13-17, Implementation: 06- 13-17)  A.  Disseminating Information   From time to time, A/B MACs must disseminate through professional relations media information regarding the prohibition in 30.2.  A/B MACs Part A   The following language may be used by A/B MACs Part A or adapted for this purpose:  The Medicare law prohibits us from paying benefits due a provider to another person or organization under an assignment, power of attorney, or any other arrangement whereby that other person or organization receives those payments directly.  There are the following exceptions to this rule:    CMS may pay a providers benefits (in the providers name) to a billing or collection agent, if:  o The agent receives the payment under an agency agreement with the provider;  o The agents compensation is not related in any way to the dollar amounts billed or collected;  o The agents compensation is not dependent upon the actual collection of payment; o The agent acts under instructions which the provider may modify or revoke at any time; and  o The agent, in receiving payment, acts only in the providers behalf.    CMS may pay the providers benefits in accordance with an assignment established by, or pursuant to the order of, a court of competent jurisdiction.   A provider should notify us immediately if:    CMS has been mailing its benefits to the address of another person or organization;    The provider has given that other person or organization power of attorney or other advance authority to negotiate its benefit checks; and     None of the above exceptions that would permit payment to another person or organization apply in the providers case.   A provider which hereafter enters into or continues such a prohibited payment arrangement may have its participation in the program terminated and its right to receive assigned payment for physician services revoked.   A/B MACs Part B and DME MACs   An A/B MAC Part B and DME MAC may use or adapt the following language for notification:  The Medicare law prohibits us from paying benefits due a physician or other supplier of health care items and services, to another person or organization, under a reassignment or power of attorney or under any other arrangement whereby that other person or  organization receives those payments directly. There are the following exceptions to this rule:   CMS may pay a physicians or suppliers employer under the terms of his/her employment.   CMS may pay a hospital, clinic, or other facility for services furnished by the physician or supplier in the facility, in accordance with the physicians or suppliers agreement with the facility.   CMS may pay a group practice prepayment plan, prepaid health plan, or    HMO for services of physicians and suppliers associated with the plan.    CMS may pay a physician, medical group, or other supplier for the technical component (TC) or professional component (PC) of diagnostic tests (other than clinical diagnostic tests) that are subject to the anti-markup payment limitation.