Wiki Q6 / Q5 modifier during credential/contract period

[Carol.Dohmen]

I have a provider that wants to use the Q6 modifier to bill for a provider that is currently pending approval of credential/contracting under his own NPI. From what I have read on the Noridian Medicare site and various articles this is not the correct use of modifier Q6 or Q5. Does anyone have experience with this? Any references I can use to explain to the provider?

 

[Chelle-Lynn]

Your situation does not meet the requirements as defined by Medicare for the use of Q5 or Q6. Per Medicare, the patient’s regularphysician may submit the claim, and receive the Part B payment, for covered visitservices which the regular physician or physical therapist arranges to beprovided by a substitute physician or physical therapist on an occasionalreciprocal basis, if:

• The regular physician is unavailable to provide the services;
• The Medicare patient has arranged or seeks to receive theservices from the regular physician
• The substitute physician does notprovide the services to Medicare patients over a continuous period of longerthan 60 days
• The regular physician indicates thatthe services were provided by a substitute physician under a reciprocal billing arrangement

The first and second requirement are the problem. The purpose of these modifiers is not to get around credentialing requirements. Doing so can open you to potential audit issues and FCA rules.

So basically for this to be appropriate, the patient would need to be seeking services from the regular provider, who is out of the office (vacation, LOA, etc) and the provider in question has a reciprocal billing arrangement documented and on file. In additional your area would need to be an underserved area or a health professional shortage area.

 

[Carol.Dohmen]

Thank you so much. That was the same information I found. I think I have explained it to him well enough. He had another provider tell him use it, so I had a hard time explaining that the other provider was incorrect.

Your situation does not meet the requirements as defined by Medicare for the use of Q5 or Q6. Per Medicare, the patient’s regularphysician may submit the claim, and receive the Part B payment, for covered visitservices which the regular physician or physical therapist arranges to beprovided by a substitute physician or physical therapist on an occasionalreciprocal basis, if:

• The regular physician is unavailable to provide the services;
• The Medicare patient has arranged or seeks to receive theservices from the regular physician
• The substitute physician does notprovide the services to Medicare patients over a continuous period of longerthan 60 days
• The regular physician indicates thatthe services were provided by a substitute physician under a reciprocal billing arrangement

The first and second requirement are the problem. The purpose of these modifiers is not to get around credentialing requirements. Doing so can open you to potential audit issues and FCA rules.

So basically for this to be appropriate, the patient would need to be seeking services from the regular provider, who is out of the office (vacation, LOA, etc) and the provider in question has a reciprocal billing arrangement documented and on file. In additional your area would need to be an underserved area or a health professional shortage area.