Avoid Billing Errors When Surgeons Need Substitutes
Published on Fri Sep 01, 2000
Surgeons temporarily unable to care for their patients have two billing options:
Enter into a reciprocal billing arrangement with
one or more other surgeons, whereby the substi-
tuting surgeon performs the service but the original surgeon bills for the service; or
Provide services to each others patients and bill for
each service or procedure performed.
The advantage of the first option reciprocal billing is that the surgeon who temporarily is unavailable still gets paid for his or her Medicare patients care. For the substituting physician, the benefit is that a new billing account need not be opened for a patient who is unlikely to visit again.
The reciprocal billing guidelines in the Medicare Carriers Manual (MCM) expand on the CPT 2000 guideline, which states: In the instance where a physician is on call for or covering for another physician, the patients encounter will be classified as it would have been by the physician who is not available.
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-based consulting firm. For example, reciprocal billing might be used when a physician has surgery and is out of commission but not long enough so that they want to bring in a locum tenens, Thompson says.
Reciprocal billing situations often are confused with locum tenens scenarios, Thompson says. But there are two main differences: (1) reciprocal billing only applies if the substitution is for less than 60 days; and (2) locum tenens usually are paid on a per diem rate, whereas, in the reciprocal coverage arrangement, the patients original physician (now unavailable) bills as though he or she performed the service.
And whereas locum tenens arrangements are identified on the Health Care Financing Administration (HCFA) claim form by using HCPCS modifier -Q6 (service provided by locum tenens physician), the reciprocal billing arrangement is indicated with modifier -Q5 (service provided by a substitute physician under a reciprocal billing arrangement).
Criteria for Billing Substitutes
According to the MCM, section 3060.6, The patients regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered services (including emergency visits and related services) that the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:
The regular physician is unavailable to provide the visit services.
The Medicare patient has arranged or seeks to
receive the visit services from the regular physician.
The substitute physician does not provide the visit services to Medicare patients over a continuous
period of longer than 60 days.
The regular physician identifies the services as
substitute physician services meeting [...]
