Oncology & Hematology Coding Alert

If done correctly, oncologists who are not in the office can bill for services the practice renders -- as long as a substitute physician is present and available for supervision or face-to-face care. 
 
Modifier -Q5 (service furnished by a substitute physician under a reciprocal billing arrangement) tells Medicare that the practice made specific arrangements with a substitute physician. The two physicians, however, must be clear on their payment arrangements to avoid billing Medicare for the same service, says Lillie McAlister, president of Double Diamond Enterprise, a coding consulting firm in Conroe, Texas.
 
The -Q5 modifier may be used only when the substitute physician is not a member of the group practice, and oncologists have two choices in billing:
 
1. Bill the services under the treating physician's provider number, or
2. Allow the substitute physician to bill for the services under his or her provider number.

 
Note: The use of a substitute physician is more common in group practices. A problem can occur, however, if the patient is a member of a PPO or HMO and the substitute physician is not part of the plan. Using the substitute's provider number may result in unjust denials.
 
The American Society of Clinical Oncology (ASCO) says either method of billing can be defended legitimately. The trick is being able to explain your choice. According to Dianna Hoffbeck, president of Northshore Medical, a coding consulting firm in Atlantic City, N.J., the treating physician should bill under his or her provider number despite being absent at the time of the visit.
 
Cancer treatment commonly follows a set of protocols that establish the treatment (such as chemotherapy) and its frequency. The protocol is typically not subject to delay or revision because the patient's physician is on vacation or out of the office. A variety of care can take place, ranging from a nurse-only visit (99211) to chemotherapy services (96400-96549).
 
Smaller practices might have only one physician on staff to provide the necessary expertise or supervision to give care within Medicare regulations. In this case, if the treating physician is on vacation or unavailable, the practice needs a substitute physician who can administer the same level of care the treating physician would.
 
For example, if a patient were scheduled for chemotherapy via infusion (96410), the substitute physician may conduct his or her own brief exam and check the patient history (the correct E/M code is chosen based on the level of service). 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 in the following manner:
 

96410-Q5 -- chemotherapy infusion, up to one hour; service furnished by a substitute physician under a reciprocal billing arrangement
 

99212-Q5 -- office or other outpatient visit; service furnished by a substitute physician under a reciprocal billing arrangement.

 
Physicians should follow these guidelines when billing for substitute services:
 

The patient's treating physician was unavailable to provide services. The use of substitute physicians was intended to address days when physicians are out sick, on vacation, or weekend coverage, ASCO says. But you'll have to rely on common sense to interpret "unavailability" because Medicare does not specifically define it or provide guidelines as to what is acceptable or unacceptable unavailability.
 

The two physicians must make specific arrangements that could include reciprocal coverage, or provide per-diem payments or other fee-for-time arrangements. According to McAlister, these agreements should be in writing and clearly understood by both physicians -- particularly those who bill Medicare. The arrangements can take several forms. They can be reciprocal agreements in which both physicians agree to trade services, so the absent physician can bill Medicare with the understanding that the same courtesy will be returned. They can also agree that the substitute receive a per-diem rate, while the treating physician bills Medicare for the services the substitute renders.
 

The substitute physician fills in for no more than 60 consecutive days. Medicare wants to ensure that the arrangement is temporary. So, the treating physician cannot bill for services beyond the 60-day period. Thus, while the substitute may cover for only a few days over a two-month period, the treating physician cannot bill for services provided by a substitute physician on the 61st day of his or her absence. However, if the treating physician is absent for 60 days and returns on the 61st day, only to leave again the next day, the process starts anew.
 

The claim must meet the requirements listed above. Appending modifier -Q5 tells Medicare that an arrangement was made to use a substitute physician because the treating physician was unavailable.
 

The provider number of the substitute physician must be included on the claim form. While Medicare requires this, its current claim form cannot support it. Until the form is revised, Medicare says the treating physician must keep a record of the days the substitute physician provided care and the specific services rendered each of those days. This document should have the physician's provider number. It is important to note that this record is not part of patient documentation, which should also include the substitute physician's notes, orders and signature.