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How to Handle -Q5 Reciprocal Billing

Published on Thu Aug 01, 2002

Consistent patient care sometimes requires physician hand-offs, but the round-robin of attending and substitute attending physicians can cause even an alert coder's head to spin. Faced with reciprocal billing, you would do well to remember the following guidelines.

If another physician covers for the patient's regular physician, the designated attending physician may submit a claim for the substituting physician's services under reciprocal billing. In such cases, the attending physician can receive payment for services provided by the substitute physician by using modifier -GV (Attending physician not employed or paid under arrangement by the patient's hospice provider) in conjunction with either modifier -Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement) or -Q6 (Service furnished by a locum tenens physician).

What Makes Locum Tenens Different

Reciprocal billing is often confused with locum tenens. However, there are two main differences:

  • Reciprocal billing requires real reciprocity, that is, both physicians cover for each other in roughly equal proportions.
  • Locum tenens are usually paid on a per-diem rate, by the absent doctor.

    Under both arrangements, the patient's absent oncologist bills as though he or she performed the service. Although "locum tenens" arrangements have been in wide use for years, as payment, it is based on a Medicare rule.

    These modifiers may also be used with third-party carriers, but make sure to ask your top-five carriers how they want services performed. The most important to remember, Hugh says, is that "a reciprocal physician cannot become a part-time physician. If you have a reciprocal physician coming in every Thursday throughout the year, he is not a reciprocal physician." Reciprocal billing wasn't designed to save practices the trouble of hiring a part-time physician, and that's where a lot of people get into trouble, Hugh says.

    -Q5 Requirements

    Emergency visits and related services are included in the reciprocal billing category, as long as they meet certain requirements, including:

  • 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 in item 24d of the HCFA 1500 claim form the -Q5 modifier after the CPT code.

    One common -Q5 variable to look out forispost-operative services furnished during the period of coverage by the global fee. During the covered postoperative period, a physiciancan perform multiplesubstitution servicesin connection with an operation. These servicesdoNOTneed to be identified on the claim as substitution services because they are part of the surgical package. And, if a physician has reciprocal arrangements with more than one physician, the arrangements need NOT be in writing.

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