Radiology Coding Alert

2 scenarios show you how to report stand-in services and get paid

 When your radiologist takes a vacation and asks another radiologist to fill in, modifiers -Q5 and -Q6 are the keys to recouping reimbursement for the substitute physician's services.

Distinguish Reciprocal Billing From Locum Tenens

"Locum tenens" physicians generally do not have practices of their own, but instead move from practice to practice, filling in for other physicians. Your radiologist pays the locum tenens physician a fixed per-diem amount as an independent contractor. Your practice, in turn, bills for the service as if your physician personally performed the service.
 
Many physicians confuse locum tenens billing with reciprocal billing, but don't use these terms inter-changeably. According to guidelines in section 3060.7 of the Medicare Carriers Manual (MCM), two main differences distinguish these scenarios:
 
1. Locum tenens physicians are paid on a per-diem rate. In a reciprocal arrangement, each physician continues to bill all services to his or her own patients.
 
2. Locum tenens arrangements are identified by appending HCPCS Codes modifier -Q6 (Service furnished by a locum tenens physician), whereas you should indicate a reciprocal billing arrangement with modifier -Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement).
 
According to the MCM, Medicare will reimburse physicians who retain locums for covered services after meeting the following criteria:
 

The regular physician is unavailable to provide the visit services.
 

The Medicare beneficiary has arranged or seeks to receive services from the regular physician.
 

The locum is an independent contractor, not an employee of the practice, and you pay him for services on a per-diem or similar fee-for-time basis.
 

The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days.

Test Yourself: Locum Tenens or Not?

Take a look at these two scenarios and the expert coding advice that follows to help you determine when the -Q modifiers may not be the best choice.

Scenario 1: Every Wednesday, your radiology group has an increase in patients when several of the hospital clinics schedule their patients for diagnostic studies. You recently hired a part-time radiologist to help out on Wednesdays and Thursdays, and you plan to bill him as a locum tenens. You intend to report him as substituting for your group's chairman (the chairman does not now practice, so this won't impact productivity for the group's other physicians).

Coding Advice: Unfortunately, this is not a true locum tenens situation. If the practice's chairman were a practicing physician who is absent on Wednesdays and therefore cannot perform the imaging services, you could report the locum tenens modifier. Because the physician in our scenario will work "in addition to" the existing staff, however, you cannot report it as a locum tenens situation.
 
If you hire the part-time physician as an employee, you should report his services using your practice's
identification number and name. No special modifiers are necessary.
 
Scenario 2: While on vacation, the radiologist in your group practice arranges for another radiologist in the same practice to see his patients. The substitute physician performs pulmonary ventilation imaging using aerosol and a single projection for a returning patient with shortness of breath and chest pain.
 
You report 78586-Q5 (Pulmonary ventilation imaging, aerosol; single projection), which means that the substitute radiologist performed the procedure under a reciprocal agreement. 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 Medicare reimburses only for reciprocal billing agreements by independent physicians who bill under their own names.
 
You should, therefore, submit the claim with 78586 using your practice's group identification number.

Group Practices: Append -Q5 With Caution

If your radiologist 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.
 
For example, if your physician bills with a PIN instead of under the group number, you would code the above service as 78586-Q5. Make sure you append 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 that the PIN indicates that another physician administered the service. If you fail to append modifier -Q5, therefore, you have not coded the physician's services to the highest accuracy, which all payers require, says Deborah Grider, CPC, CPC-H, CCS-P, CCP, president of Medical Professionals Inc. in Indianapolis.
 
Modifier -Q5 most commonly applies when one solo physician alternates weekends or vacations with another solo practitioner nearby. If you fill in for another radiologist during the weekend, you would not bill for the service. Instead, the other radiologist would submit a claim for the service with modifier -Q5 appended to tell the Medicare carrier that he did not personally perform the service.