Pediatric Coding Alert

Question: Can we use modifiers Q5 and Q6 for non-credentialed "moonlighting" physicians? These out-of-house residents mainly see patients in the extended hours clinic, which is similar to urgent care.

California Subscriber

Answer: Moonlighting arrangements fall under locum tenens, which Medicare requires you to indicate with its modifier Q6 (Service furnished by a locum tenens physician). Private payers have no equivalent billing modifier, but you might still want to use Q6 and its guidelines to protect your arrangements. 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 Q6 as Medicare requires and accepts. Just make sure you adhere to the following guidelines.

Under locum tenens arrangement, your pediatric practice would pay the moonlighting resident for services provided on a per-diem or similar fee-for-time basis. You would bill the service under the urgent care group's national provider identifier (NPI) as you normally would. To indicate a substitute physician is actually providing these services, you should append modifier Q6 to the CPT codes, such as 99201-99215 (Office or other outpatient services ...) and when appropriate 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service). Then, list the medical group physician's NPI for whom the substitution services are furnished in item 24k on the CMS-1500 claim form or electronic equivalent. This requirement implies that the resident has enrolled in Medicare and received an NPI.

Make sure you also meet these Medicare locum tenens documentation requirements:

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

2. The group must retain a copy of each service the substitute physician provides, along with the substitute physician's NPI number.

You do not have to directly worry about how many extra hours the resident is working. Moonlighting at a separate institution does not count toward the Accreditation Council for Graduate Medical Education's (ACGME) 80-hour workweek limit.

Beware: Locum tenens arrangements are one-way exchanges as your description indicates. Reciprocal billing arrangements involve two physicians alternating services, such as weeks or weekends off, and fall under modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement).

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