Oncology & Hematology Coding Alert

Question: We now report the provider number of the physician who makes rounds and does the consults in the hospital. The chief financial officer of our practice wants us to use the provider number of the physician of record in our clinic, no matter which physician made the rounds. I've always billed with the provider number of the provider of service. Is it correct to use the provider number of the admitting physician, who is on vacation?

Oklahoma Subscriber

Answer: If the physician who steps in for an absent treating physician is part of the same oncology practice, you may report the provider number of the admitting physician, despite his or her absence.

When a substitute physician from outside the practice is used, oncology practices have two choices:

1. Bill the services under the treating physician's provider number as "incident to" services

2. Allow the substitute physician to bill for the service under his or her provider number.

According to the American Society of Clinical Oncology (ASCO), either method of billing can be defended. Whichever option you choose, you must be able to defend your choice. Still, ASCO advises oncology practices whether they bill for the absent treating physician or for the present supervising physician to identify the physician who is present to avoid any appearance of fraud.

Cancer treatment commonly follows a set of protocols, which establish the method, such as chemotherapy, and its frequency and follow-up. The protocols are typically not delayed or revised because the patient's physician is on vacation or out of the office. The substitute should provide the same level of care that the treating physician would have given if he or she had been present.

For example, if the patient was scheduled for chemotherapy via infusion, 96410 (... infusion technique, up to one hour), the physician may conduct his or her own brief exam in the hospital where the patient was admitted and bill 99231 (Subsequent hospital care). Although the substitute physician provided face-to-face care and the staff provided care that was incident to the substitute's services, the treating physician is still entitled to bill for those services using the -Q5 modifier (Service furnished by a substitute physician under a reciprocal billing arrangement). The -Q5 modifier requires either informal or formal arrangements made by both physicians to trade services. With all that in mind, oncology practices should code the above example as 96410-Q5, 99231-Q5.

Medicare recognizes that the treating physician may be unavailable. Guidelines that must be followed for physicians to bill for care despite their absence state: