Oncology & Hematology Coding Alert

Question: Our medical oncologist has two offices and is in our office two-and-a-half days per week. He and a radiation oncologist have an agreement to cover for each other when one of them is out. When we do radiation treatments and the radiation oncologist is out, should we use the -Q5 modifier when billing Medicare, even if the medical oncologist isnt providing the service?

Arizona Subscriber

Answer: The rules vary by payer. Under the scenario described, the -Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement) seems appropriate, but the reciprocal arrangement could be called into question. First, the concept of reciprocal arrangements between physicians is a Medicare convention. It does not apply to any other payer, unless they specifically have a policy that provides for the substitution of one physician for another. Our experience has been that managed-care entities and traditional indemnity insurance companies will not recognize reciprocal arrangements.

Some Medicare payers insist that the reciprocal physician be of the same specialty. For example, it would not be acceptable for a medical oncologist to substitute for a radiation oncologist. Others will authorize substitution providing the substitute physician has the same skill set. With radiation oncology, there is a potential risk-management issue, because the medical oncologist may not be familiar with the blocking, wedges, etc.

In general, the patients regular physician may submit the claim and receive Part B payment for covered visit services that the regular physician arranges to be provided by a substitute on an occasional reciprocal basis, if the following requirements are met:

The regular physician is unavailable to provide the visit services;

The Medicare patient has arranged or seeks to receive the visit services from the regular physician;

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

The regular physician enters the -Q5 modifier after the procedure code in item 24d on the HCFA 1500 HCPCS Q5 form.

In addition, the patients regular physician must keep a record of each service provided by the substitute including the unique provider identification number (UPIN).

This question was answered by Cindy C. Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a coding consulting firm in Dallas, Ga.