Oncology & Hematology Coding Alert

Here's how to report stand-in services and get paid

While the oncologist takes summer vacation, can he still get paid for chemotherapy treatments? Sure, if you know when and how to report modifiers -Q5 and -Q6.

Reciprocal billing allows a physician to submit claims and receive Medicare payments when he has arranged for a substitute physician's services. To report this arrangement, append -Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement).

Locum tenens also allows the physician to receive payment for services another physician performs, but a locum tenens physician cannot work for another practice, and your physician cannot restrict the locum's services to your office. Also, the physician pays a locum on a per-diem or fee-for-time basis, says Jean Acevedo, CPC, LHRM, senior consultant, Acevedo Consulting Inc., Delray Beach, Fla.

When a locum performs a service or procedure, attach modifier -Q6 (Service furnished by a locum tenens physician) to the appropriate code.

Review these two locum tenens scenarios and the expert coding advice that follows to help you apply the -Q modifiers correctly:

Scenario one: Your practice hires a locum tenens oncologist for 90 days while your practice searches for candidates to fill a vacant position. On his first day, the locum tenens oncologist infuses chemotherapy for an hour (96410, Chemotherapy administration, intravenous; infusion technique, up to one hour).

Coding advice: Many oncology coders and oncologists mistakenly believe a practice cannot hire a locum physician or use modifier -Q6 for a locum's services if the substitute physician works for an oncologist who has left the practice.

But you could append modifier -Q6 to 96410 to inform Medicare that it should pay your physician for the locum's chemotherapy services.

However, Medicare doesn't allow you to use modifier -Q6 if the locum physician performed the procedure after his 60th day working for your practice, Acevedo says. Therefore, if the locum administered chemotherapy (96410) on the 61st day of service, you could not use -Q6.

Scenario two: While on vacation, the oncologist in your group practice arranges for another oncologist in the same practice to see a patient for prolonged chemotherapy treatment. The substitute physician performs a prolonged infusion (96410, +96412, ... infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]). You report 96410, 96412-Q5, which means the substitute oncologist performed the infusion under a reciprocal agreement. Your billing specialist submits the claim under the group number.

Coding advice: The Medicare carrier will probably deny your claim because you cannot use reciprocal billing arrangements for services or procedures that a member of the same group provides.

CMS rules state that it reimburses only for reciprocal billing agreements made among independent physicians who bill under their own names.

If your oncologist works in a group practice that submits your physician's claims under his provider identification number (PIN), not the group number, you may use modifier -Q5 for reciprocal billing arrangements. Medicare considers physicians who bill under their names as "independent" of the group practice when it comes to reciprocal agreements.

For example, if your physician bills with a PIN instead of the group number, the carrier will likely pay for 96410, 96412-Q5. Make sure you append modifier -Q5 when allowed because Medicare may deny your claim if you neglect to append the modifier.

A CMS claims reviewer may notice that the claim contained one physician's billing number but that the PIN indicates that another physician administered the service. If you fail to append modifier -Q5, therefore, you have not coded the physician's services to the highest accuracy, which all payers require, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis.

Typically, modifier -Q5 applies when one solo physician alternates weekends or vacations with another solo practitioner nearby. If the physician fills in for another oncologist during the weekend, you would not bill for the service. Instead, the other oncologist would submit a claim for the service with modifier -Q5 appended to tell the Medicare carrier that he did not personally perform the service.