Pulmonology Coding Alert

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

Ohio Subscriber

Answer: As per section 30.2.10 in the Medicare Claims Processing Manual (www.cms.gov/manuals/downloads/clm104c01.pdf), you can report your pulmonologist's (who is away on vacation) name for the claims. 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 services;

• The Medicare patient arranged or seeks services from the regular physician;
• The substitute physician is certified with the Medicare Part B carrier, is not employed by the regular physician, and has his/her own practice;
• 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 claim
• Until further notice, the regular physician must maintain the records for each service provided by the substitute physician, and make this record available to the carrier upon request.

Group billing: If the substitute physician is a member of the same group practice that 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 pulmonologists in your group do not bill as a group, but have separate practices and bill exclusively in their own names, treat them the same as independent pulmonologists under the Medicare reciprocal billing rules.