MEDICARE Q&A: Mid-Summer Update Print
Written by Benjamin L. Frosch   
Sunday, 25 July 2010 13:48

Q:   I am a solo practitioner who specializes in cardiology.  One of the tests that I perform in my office is echocardiography.   During very busy periods, I may not provide a full interpretation and report of my echocardiograms for a few months.  I understand that I cannot bill Medicare until the service is complete and therefore wait until I have provided a full interpretation and report.  As a result, I may not bill Medicare for those services for over a year period.  Has there been a change with respect to the time period of submitting claims to Medicare?


Tampa, FL

A:  As a result of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) will only pay for claims with dates of service on or after January 1, 2010 up to a year. Claims received later than one calendar year beyond the date of service will be denied by Medicare.  Therefore, you should not submit claims to Medicare that are more than one year old.  

Another point that you should consider is that by taking so much time to interpret these echocardiograms, Medicare could take the position that these services were not medically reasonable and necessary in treating and managing the patient.   So even if you submit claims for echocardiography on or after January 1, 2010 and forward them to Medicare months after performing the echocardiogram, you may still have an issue pertaining to why you waited so long to interpret those echocardiograms. 


Q: We have a Locum Tenens physician who next week will be with us for sixty days.  It is our understanding that sixty days is the Medicare "cutoff" for a locum tenens physician which allows us to use the Q6 modifier.   The provider enrollment process is very cumbersome and I was wondering that once our Locum Tenen physician reaches the sixty day period, can the Locum Tenens Physician take a day off and the sixty day Medicare period begin again?

Office Manager

Palm Beach, Fl

A:     If the regular physician requires services of a Locum Tenens physician for a period longer than sixty days, the substitute physician needs to enroll with the group practice.   The Locum Tenen physician should complete a CMS 855R reassigning his/her benefits to the practice.   Otherwise, the substitute physician "taking a day off" is not a consideration in the Medicare guidelines of Locum Tenens for establishing the sixty day period.  

CMS guidelines state that a regular physician may bill for the services of a Locum Tenens physician providing that the following guidelines are met:

A.    The regular physician is unable to provide visit services.

B.   The substitute physician does not provide services over a continuous period longer than sixty-days.

C.    The Medicare beneficiary has arranged for or seeks to receive services from the regular physician.

D.    The regular physician pays the Locum Tenens for services on a per diem or similar fee for time basis


Q:  I am a non-participating surgeon. I performed a surgery on a Medicare beneficiary that was very complex and time consuming.   Because the claim was submitted unassigned, the beneficiary received the payment which was very low for the surgery performed. The patient is elderly and would have difficulty filing an appeal.  Can I file the appeal on behalf of the beneficiary?


South Florida

A:  Yes,under certain circumstances. The beneficiary may complete an appointment of representation form (CMS 1696) which can be found at  This form is used to authorize an individual to act as a beneficiary's representative in connection with a Medicare appeal. As a representative, you would be able to help your Medicare patient during the processing of the claim and any subsequent appeals.


Q:  We tried to provide our patients with the highest quality of care. For our established patients, we have started to treat them on an "emergency" basis after hours at our office.  Is it necessary for us to attach modifier 25 (indicating a significant, separately identifiable E/M visit on the same date as another procedure) to our follow-up visits in order to additionally bill Medicare procedure code 99058 (services provided on an emergency basis in the office, which disrupts other scheduled office services in addition to basic service)?

Office Manager

Boca Raton, Fl

A:   CPT code 99058 is not a recognized service that is billable to the Medicare program.   The E&M follow-up visits will have to be billed according to the actual level of care that is provided to the patient.  There is no additional reimbursement by Medicare for disruption of other scheduled services or after hour services in your office.     



Last Updated on Sunday, 14 August 2011 14:11