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Practice Management Alert

What Goes Around, Comes Around:

Your Guide to Reciprocal and Locum Tenens Billing

Published on Fri Nov 01, 2002

Mastering the details of reciprocal and locum tenens billing is enough to make any medical office biller want to take a long leave of absence. But if you don't understand and follow the rules, you are leaving your practice vulnerable to denied claims and compliance violations.

Reciprocal billing means that one doctor has promised to see another doctor's patients while she is away. The absent doctor later returns the favor when needed, says Lisa Johnson, CPC, CCS-P, a senior consultant with Gates, Moore and Company, based in Atlanta.

You shouldn't file reciprocal billing claims for call coverage within medical groups, Johnson stresses. Reciprocal billing does not apply to substitute arrangements within a medical group for claims submitted under a group name, she says.

When applicable, substituting under reciprocal billing arrangements benefits both the regular and substitute physician. A regular physician who is unavailable to see patients secures for them continued quality service without losing payment for her time away. The substitute physician fills in for his fellow physician without the hassle of creating new files for patients who are unlikely to be seen again during the changeover, say Susan Callaway CPC, CCS-P, a coding and reimbursement specialist in North Augusta, S.C.

Under a similar arrangement called locum tenens, the regular physician receives payment for time off but then parcels out a fee-for-time payment to the substitute who provides a service on a more regular basis (see related article 2).

Guard Against Compliance Risks

To legitimize payment, your claims must be absolutely clear and up-front about reciprocal billing arrangements.

Here's an example of how reciprocal billing can present compliance risks. Let's say Dr. Smith has worked 20 years for a busy internal medicine practice and finally takes time off for an eight-week vacation. She asks her trusted colleague Dr. Jones to see her regular patients while she's gone. However, the practice doesn't note this arrangement in its records or claims because the two doctors assume they have worked out a private agreement and that Dr. Jones is simply doing his friend a favor.

But what looks like a favor to the doctors may look like a bunch of false claims to a payer. Private agreements for substitute physicians need a mention in the regular physician's claim. Fudging this detail invites denials. Your local Medicare carrier might find out about the slip-up during a random inquiry and deny your physicians for two months of service, Johnson warns.

Reciprocal Billing Criteria

When you submit a reciprocal billing claim to Medicare, you should verify the following, Johnson advises:

  • The patient arranged or sought to receive covered services from a regular physician.
  • The regular physician was unavailable.
  • The substitute physician who replaced the regular physician provided services on an occasional reciprocal basis for a continuous period no greater than 60 days.

    While most private payers have reciprocal billing rules similar to Medicare's, you should check your contracts with payers to make sure.

    If the substitute physician renders services not covered for patients seeking consult from their regular physicians, you cannot request reciprocal billing payment for them, Johnson says. Although extenuating circumstances allow you to bill Medicare for services not normally covered, these scenarios are the exception, not the rule.

    You should also inform your entire office about the 60-day limit for allowing substitute physicians. Advise your physicians to consult a calendar before they enter into a reciprocal billing arrangement, Johnson says. Let them know that after 60 days into the agreement, the regular physician is no longer entitled to payment for the substitute's services. What physicians may not know, Johnson states, is that the substitution period covers weekend days. Advise physicians not to make the error of scheduling for a business-day calendar.

    Use the -Q5 Modifier

    When you fill out a CMS 1500 form for a reciprocal billing claim, you must indicate the service as the regular physician's, appending the relevant CPT code with modifier -Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement), Johnson says.

    Append -Q5 to all services the substitute has rendered except for postoperative services furnished during the global surgical period, Johnson says (post-op codes have zero reimbursement, so they're basically negligible to carriers). If the substitute physician performs two procedures on the same day, append -Q5 to both, she says.

    Submit the claim under the regular physician's name and provider number; you've indicated the substitute with the modifier, Johnson states.

    For medical group billing, if the substitute physician is not a part of the medical group, the group can bill for reciprocal billing by entering modifier -Q5 after the CPT code in item 24D of the claim form, Johnson says. Add the pin number of the group's absent physician in block 24K of the appropriate line item, she adds. Electronic submitters should refer to charts on their local Medicare carrier's Web site to find filing rules.

    Once you've filed reciprocal billing claims, it's imperative that you keep a record of them. Medicare carriers eyeball claims with modifier -Q5 even though it doesn't change the payment, Johnson says. The modified claims reveal an unusual physician situation that could interest your carrier if the substitutions became frequent or permanent.

    Keep the records in your regular physician's file, with the substitution physician's UPIN number attached, Johnson says. Have this information available by request, but you don't need to submit the substitute's number with the claim form, she adds. $ $ $

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