General Surgery Coding Alert

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 the
requirements of this section by entering the -Q5
modifier in item 24d of the HCFA 1500 claim form.

The guidelines for reciprocal billing and the use of the -Q5 modifier also apply to physicians in the same group practice. Medicare wants to know if a different physician provided the billed service, even if both physicians are in the same group and use the same tax identification number.

Note: If the -Q5 modifier is not attached, neither physician is likely to get paid (if the claim is pre-audited) because the Medicare carrier will see a claim by one physician, whereas the documentation states the service was provided by another. As the substituting physician did not file a claim, no payment for the service would be forthcoming.

The guidelines also state that the substituting unique physician identification number (UPIN) must be included in box 23 of the HCFA 1500 claim form, Thompson notes, to inform Medicare of the identity of the physician who actually saw the patient.

Using reciprocal billing allows physicians to fill in for their colleagues without the hassle of creating new files for patients that are unlikely to be seen again, according to Susan Callaway-Stradley, CPC, CCS-P, a coding and reimbursement specialist in North Augusta, S.C.

Reciprocal billing arrangements often are used with hospital admissions, she says. Say surgeon B is covering for surgeon A for the weekend and has to admit a patient.
When surgeon A returns, hell take over the patients care. So surgeon B admits the patient but doesnt bill for the admission. Instead, surgeon A bills for the service, making sure to include both the -Q5 modifier and surgeon Bs UPIN number.

Callaway-Stradley points out that in the event of an audit, if the documentation indicates another physician performed the service, payment will be denied unless a reason can be shown for why the regular surgeon is billing for it, which is the role of the -Q5 modifier.

According to MCM section 3060.6, a physician may have reciprocal arrangements with more than one alternate physician, and these arrangements need not be in writing.
The reciprocal billing arrangement can apply to any situation as long as the physicians absence does not exceed 60 days. Care provided by the substituting physician does not constitute follow-up care already included in the global surgical package of a procedure performed by the now-unavailable surgeon, Callaway-Stradley adds.

Follow-up on Patients in a Global Period

If the services provided by the substitute physician are considered part of a surgical global period (for example, follow-up care on a patient after abdominal surgery), the -Q5 modifier need not be appended, according to MCM section 3060.6, because the services are bundled to the original procedure performed by the original physician and are not payable in any event.

If, however, the patient has a separately identifiable problem, the visit could be billed by the original physicians office with modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period).

If the original physician became unavailable immediately after performing a procedure, and the substitute physician must perform the bulk of the follow-up care and doesnt have a reciprocal arrangement with the now-unavailable surgeon, he or she may be able to bill for the follow-up care by attaching modifier -55 (postoperative management only) to any evaluation and management services or procedures performed. Such claims may not be honored unless the office of the physician who performed the procedure agrees to attach modifier -54 (surgical care only) to the original service indicating that postoperative care would be handled by another physician. In these instances, the fee charged by the original physician should be reduced to reflect the fact that postoperative services are not included.