Otolaryngology Coding Alert

2 scenarios show you how to report stand-in services

 When your allergist takes a vacation and arranges for another allergist to fill in, you'll need to know how to use modifiers -Q5 and -Q6 to report the substitute physician's services.

Distinguish Reciprocal Billing From Locum Tenens

Reciprocal billing allows a physician to submit claims and receive Medicare payments for a substitute physician's services. To report this arrangement, attach -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, a senior consultant at Acevedo Consulting Inc. in Delray Beach, Fla.
 
When a locum performs a service or procedure, use modifier -Q6 (Service furnished by a locum tenens physician).
 
Take a look at 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 allergist for 90 days as your practice searches for candidates to fill a vacant position. The locum tenens treats a patient who presents with possible asthma. After an evaluation, the allergist decides spirometry will help diagnose the problem. The substitute physician performs a bronchodilation and follows up with another spirometry test to confirm the asthma diagnosis. 
 
Coding Advice: Many allergists and allergy coders 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 allergist who has left the practice. But in this case, you could attach modifier -Q6 to 94060 (Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) for the locum's bronchospasm evaluation. You cannot code separately for the spirometry (94010) or the bronchodilation (94664) because the National Correct Coding Initiative (NCCI) bundles the service into the bronchospasm test.
  
Medicare, however, doesn't allow you to use modifier    -Q6 if the locum physician performed the procedure after his or her 60th day working for your practice, Acevedo says. Therefore, if the locum administered a bronchospasm evaluation on the 61st day of service, you would report 94060 without -Q6.
 
Scenario Two: While on vacation, the allergist in your group practice arranges for another allergist in the same practice to see a patient for allergic rhinitis. The substitute physician performs an office consult (99244, ... for new or established patient) and an allergy injection (95115, Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection). You report 95115-Q5, which means the substitute allergist performed the injection under a reciprocal agreement. You don't list 99244 because you believe you can't report E/M services with 95115. Your billing specialist submits the claim under the practice's 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 by independent physicians who bill under their own names.
 
Therefore, you would submit 95115, linking diagnosis code 477.x (Allergic rhinitis) as medical justification. Also, you may be able to bill for 99244. To help support the medical necessity of the office consult, consider linking a different diagnosis code to the office visit than the one you used for the injection, coding experts say. For example, link V58.69 (Long-term [current] use of other medications) and 493.xx (Asthma) to 99244.
 
In addition, attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99244, or Medicare will deny your claim, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis.

Use a PIN for Reciprocal Services

If your allergist works in a group practice that submits your physician's claims under his or her provider identification number (PIN), not the group number, you may use modifier -Q5 for reciprocal billing arrangements. That's because Medicare considers physicians who bill under their names as "independent" of the group practice when it comes to reciprocal agreements, the Medicare Carriers Manual states.
 
For example, if your physician bills with a PIN, you would code the office consultation and injection as 99244-Q5 and 95115-Q5. Make sure you apply modifier -Q5 when allowed because Medicare may deny your claim if you neglect to attach the modifier. A CMS claims reviewer may notice that the claim contained one physician's billing number, but the PIN indicates that another physician administered the service. Therefore, by not using -Q5, you have not coded the physician's services to the highest accuracy, which all payers require, Grider says.