Psychiatry Coding & Reimbursement Alert

Question: If our psychiatrist goes for a vacation and another psychiatrist from our own group provides services for his patients, whose name should be reported for the claims?

Ohio Subscriber

Answer: As explained below, it will depend on whether or not you typically submit claims in the name of the group. In general, section 30.2.10 of chapter 1 in the Medicare Claims Processing Manual (www.cms.gov/manuals/downloads/clm104c01.pdf) allows you to report your psychiatrist’s (who is away on vacation) name on the claims for services provided by a substitute physician. However, you must remember that there are several rules that need to be followed as is mentioned in the manual. Payment can be issued if the regular physician arranges a substitute physician to furnish services on an occasional reciprocal basis in the following circumstances:

The regular physician is unavailable to provide the services;

The Medicare patient arranged or seeks services from the regular physician;

The substitute physician services occur over a continuous period < 60 days; and

Modifier Q5 (service furnished by a substitute physician under a reciprocal billing arrangement) is used with each appropriate item on the claim

Until further notice, the regular physician must maintain the records for each service provided by the substitute physician, associated with the substitute physicians’ national provider identifier (when required), and make this record available to the Medicare carrier or administrative contractor upon request.

Group billing: If the substitute physician is a member of the same group practice as the regular physician and the group submits claims using a group ID, apply rules for group billing: the group physician who actually performed the service must be identified. The only exception is hospice claims where the hospice attending physician of record requires a substitute physician from the group. Since only one physician may be assigned as a hospice attending of record, modifier Q5 may be used in this latter scenario by the designated attending physician to bill for services related to a hospice patient’s terminal illness.

If the psychiatrists in your group do not bill as a group, but instead bill exclusively in their own names, treat them the same as independent psychiatrists under the Medicare reciprocal billing rules.