Oncology & Hematology Coding Alert

Question: When one oncologist goes on vacation and a physician from the same group covers those days, whose name should appear on the claim?

Florida Subscriber

Answer: The patient's regular physician may submit the claim and receive payment, according to section 30.2.10 of the Medicare Claims Processing Manual (www.cms.gov/manuals/downloads/clm104c01.pdf). There are, of course, several conditions the visit must meet, which you may read about in the manual.

One condition you want to be sure to meet as a coder is that you must append modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement) to the code for the procedure the substitute physician provides.

Group billing: If your group submits claims under a group ID, be sure to read the sections specific to that circumstance.

For example, the manual explains that "On claims submitted by the group, the group physician who actually performed the service must be identified." The exception is that "When a group member provides services onbehalf of another group member who is the designated attending physician for a hospice patient, the Q5 modifier may be used by the designated attending physician to bill for services related to a hospice patient's terminal illness that were performed by another group member."

If the physicians in your group bill in their own names, treat them the same as independent physicians under the Medicare reciprocal billing rules.