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Internal Medicine Coding Alert

Reader Question:

Reciprocal Billing Arrangements

Published on Fri Feb 01, 2002

Question: Our physician has to cut back temporarily on his work schedule while recovering from a recent illness. He has made arrangements with another physician to cover for him. Our physician wants to bill for the substitute physicians services. How should we code these services?

Florida Subscriber
 
Answer: A reciprocal billing arrangement is legal and is recognized by Medicare, which has published a detailed set of rules governing this arrangement in the Medicare Carriers Manual. Medicare allows the billing arrangement that you described under the following circumstances:

  the arrangement is only on an occasional basis and lasts no longer than 60 days
  the regular physician is unavailable to provide the service
  the patient has requested the service from his or her regular physician. 
 
You code for the substitute physician as you would for the regular physician. Thus, patients who are established with your practice would still be billed as established patients when seen by the substitute physician even though they are new to the substitute physician. Modifier -Q5 (service furnished by a substitute physician under a reciprocal billing arrangement) must be attached to each service billed. There is no requirement to identify the name or UPIN of the substitute physician on the claim form, but the billing physician is required to keep on file a record of the substitute physicians UPIN and all services rendered by the substitute physician. This record must be made available to Medicare upon request. A physician may have reciprocal arrangements with more than one physician, and the arrangements need not be in writing.
 
Reciprocal billing arrangements do not apply to physicians in the same group practice. When one member of the group substitutes for another, each group member must bill services under his or her own name. Not every payer recognizes reciprocal billing arrangements or the -Q5 modifier. Ask your local payers if they follow Medicares rules. You can reference Medicares rules in the Medicare Carriers Manual, section 3060.6.

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