Otolaryngology Coding Alert

Question: When our otolaryngologist is out of town on emergency or on vacation and we call another ENT physician or ENT resident to -cover- or perform services, can we bill the services the -covering physician- is doing under our doctor's national provider identifier (NPI)? Our doctor would need to sign all charts and document that -so and so- was covering, correct?


New Mexico Subscriber

Answer: Yes. Under locum tenens arrangements, your otolaryngologist would pay the substitute ENT for services provided on a per-diem or similar fee-for-time basis. You would bill the service under your otolaryngologist's NPI as you normally would. To indicate that a substitute physician is providing these services, you should append modifier Q6 (Service furnished by a locum tenens physician) to the CPT codes.   

Remember: The substitute physician's services may not continue beyond a continuous period of 60 days.

Beware: Locum tenens arrangements are typically random and unplanned as your description suggests, but if your otolaryngologist plans to alternate services with another ENT, they might instead have reciprocal billing arrangements. For instance, they may decide to exchange vacation weeks--your ENT goes on vacation for one week in the spring when ENT B covers for him, and ENT B goes on vacation in the fall for one week while your physician sees ENT B's patients.

In these situations, the doctor who owns the patients, not necessarily the one who saw them at those visits, bills out performed services other than included postoperative care. The idea is that the provided services balance out during the time. The physician billing the services uses modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement) to indicate he really did not see the patient.

Private payers have no equivalent reciprocal billing modifier, but you might still want to use Q5. If you are audited and the auditor questions your billing of patients your physician did not see, you can explain that you indicated this with modifier Q5 as Medicare requires and accepts.

Reciprocal billing arrangements also carry the restriction that the substitute physician may not provide the services over a continuous period of longer than 60 days.

For more information on reciprocal billing arrangements and locum tenens arrangements, see the Internet-Only Manual (IOM) 100-04 Chapter 1, 30.2.10-11, available at the CMS Web site.

You Be the Coder and Reader Questions answered/reviewed by Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City.