Under reciprocal billing arrangements, a patient’s absentee physician may submit a claim and receive payment for services arranged to be provided by a substitute physician on an occasional basis. The regular physician should identify the service as substitute physician services and bill with the Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement).
A reciprocal billing arrangement is typically an agreement among physicians that one will cover the others practice when the physician is absent. Reciprocal billing arrangements are usually informal, and Medicare does not require them to be in writing. The absentee physician compensates the covering physician by reciprocating in the future. Physicians may have reciprocal billing arrangements with more than one physician.
Coverage periods for reciprocating physicians are typically brief, although Medicare will allow them to last up to 60 days if certain criteria are met. A typical example of a reciprocal billing arrangement is a physician who covers for an absentee physician who is on-call for the weekend.
Q5 Definition: Services furnished by a substitute physician under a reciprocal billing arrangement.
Appropriate Usage
When a physician agrees to see patients of another physician under arrangements of the original physician
• The regular physician is not available to see patients
• The patient arranges or seeks service of their regular physician
• Short term coverage provided, under 60 days
• When a group member acts on behalf of a hospice attending physician
Inappropriate Usage
• When the physician is covering for an absence of a long term
• When the physician is in the same group and same specialty
Locum tenens’ are substitute physicians who assume professional practices in the absence of a regular physician for reasons such as illness, pregnancy, vacation, or continuing medical education. The substitute physicians generally have no practice of their own and move to various facilities as needed. Medicare rules require that locum tenens cannot provide services for longer than 60 days.
The absentee physician pays the locum tenens physician an agreed upon rate, with the locum tenens acting as an independent contractor rather than an employee. The absentee physician may submit a claim using the Q6 modifier (services furnished by a locum tenens physician). Also, the regular physician must keep on file a record of each service provided by the locum tenens along with the locum tenens’ UPIN.
Q6 Definition: Services furnished by a Fee-For-Time Compensation Arrangements physician.
Appropriate Usage
• When a physician agrees to see patients of another physician under arrangements of the original physician
• The regular physician is not available to see patients
• The patient arranges or seeks service of their regular physician
• Short term coverage provided, under 60 days
• The physician seeing the patient is not in practice for themselves, or employed as part of another practice
Inappropriate Usage
• When the physician is covering for an absence of a long term
• When the physician is in the same group
• When the absent physician is deceased and the group is attempting to re-use their PTAN number
This is my opinion.
Michael G. Warshaw
DPM, CPC
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