Pulmonology Coding Alert

Get what you deserve with these 2 modifiers

The pulmonologist's choice of a locum physician or a reciprocal billing arrangement when he takes vacation or calls in sick determines whether you should attach modifiers -Q5 or -Q6 to the appropriate procedure and service codes.

Choose Between Reciprocal and Locum Billing

Reciprocal billing allows a physician to submit claims and receive Medicare payments when he has arranged for a substitute physician's services. To report this arrangement, attach -Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement).
 
Locum tenens also allows pulmonologists to receive payment for services another physician performs, but a locum tenens physician cannot work for another practice, and your physician cannot restrict the locum's services to your office. Also, your pulmonologist pays a locum on a per-diem or fee-for-time basis, says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society in Boca Raton.
 
When a locum performs a service or procedure, use modifier -Q6 (Service furnished by a locum tenens physician), Berman says.
 
Take a look at two locum tenens scenarios and the expert coding advice that follows to help you apply the Q modifiers correctly:
 
Scenario One. Your practice hires a locum tenens pulmonologist for 90 days as your practice searches for candidates to fill a vacant position. The locum physician performs a bronchoscopy (31622, Bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) to inspect a patient's lung. After finding a lesion, the physician takes a biopsy (31625, ... with biopsy) of the lesion.
 
Coding Advice: Many pulmonology coders and pulmonologists mistakenly believe a practice cannot hire a locum physician or use modifier -Q6 for a locum's services if the substitute physician works for a pulmonologist who has left the practice.
 
But you could attach modifier -Q6 to 31625, although you would not separately report 31622, which the National Correct Coding Initiative bundles into the biopsy code. Medicare, however, doesn't allow you to use modifier -Q6 if the locum physician performed the bronchoscopic biopsy after his or her 60th day working for your practice.
 
Therefore, if the locum administered the bronchoscopy with biopsy (31625) on the 61st day of service, you could not use -Q6.
 
Scenario Two. While on vacation, a pulmonologist in your group practice arranges for another pulmonologist in the same practice to treat a patient for excessive fluid in the pleural space (511.1, Pleurisy; with effusion, with mention of a bacterial cause other than tuberculosis). The substitute physician performs an office consult (99244, ... for a new or established patient) and a thoracentesis (32000*, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) to remove the excessive fluid. You report 32000-Q5, which means the substitute pulmonologist performed a thoracentesis under a reciprocal agreement. You don't list 99244 because you believe you can't report E/M services with 32000. Your billing specialist submits the claim under the practice's group number.
 
Coding Advice. The Medicare carrier will probably deny your claim because you cannot use reciprocal billing arrangements for services or procedures that a member of the same group provides. CMS rules state that it reimburses only for reciprocal billing agreements made among independent physicians who bill under their own names.
 
Therefore, you would submit 32000, linking diagnosis code 511.1 as medical justification. Also, remember that because thoracentesis (32000) is a starred procedure, the code includes only surgical services, so Medicare allows you to assign 99244 to the physician's office consultation service. But you must append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99244 or Medicare will deny your claim, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis.
 
Also, to justify the physician's E/M service, list the underlying condition that led to the consultation, such as 511.1 (Pleurisy ...).
 
But if your pulmonologist works in a group practice that submits your physician's claims under his or her provider identification number (PIN), not the group number, you may use modifier -Q5 for reciprocal billing arrangements. That's because Medicare considers physicians who bill under their names as "independent" of the group practice when it comes to reciprocal agreements, the MCM states.
 
For example, if your pulmonologist bills with a PIN, you would code the office consultation and thoracentesis as 99244-Q5 and 32000-Q5. And make sure you apply modifier -Q5 when allowed, because Medicare may deny your claim if you neglect to attach the modifier. A CMS claims reviewer may notice that the claim contained one physician's billing number but the PIN indicates that  another physician administered the service. Therefore, by not using -Q5, you have not coded the physician's services to the highest accuracy, which all payers require, Grider says.