Use Modifier -Q5 for Substitute-Physician Services
Published on Wed Aug 01, 2001
If done correctly, oncologists who are not in the office can bill for services the practice renders -- as long as a substitute physician is present and available for supervision or face-to-face care.
Modifier -Q5 (service furnished by a substitute physician under a reciprocal billing arrangement) tells Medicare that the practice made specific arrangements with a substitute physician. The two physicians, however, must be clear on their payment arrangements to avoid billing Medicare for the same service, says Lillie McAlister, president of Double Diamond Enterprise, a coding consulting firm in Conroe, Texas.
The -Q5 modifier may be used only when the substitute physician is not a member of the group practice, and oncologists have two choices in billing:
1. Bill the services under the treating physician's provider number, or
2. Allow the substitute physician to bill for the services under his or her provider number.
Note: The use of a substitute physician is more common in group practices. A problem can occur, however, if the patient is a member of a PPO or HMO and the substitute physician is not part of the plan. Using the substitute's provider number may result in unjust denials.
The American Society of Clinical Oncology (ASCO) says either method of billing can be defended legitimately. The trick is being able to explain your choice. According to Dianna Hoffbeck, president of Northshore Medical, a coding consulting firm in Atlantic City, N.J., the treating physician should bill under his or her provider number despite being absent at the time of the visit.
Cancer treatment commonly follows a set of protocols that establish the treatment (such as chemotherapy) and its frequency. The protocol is typically not subject to delay or revision because the patient's physician is on vacation or out of the office. A variety of care can take place, ranging from a nurse-only visit (99211) to chemotherapy services (96400-96549).
Smaller practices might have only one physician on staff to provide the necessary expertise or supervision to give care within Medicare regulations. In this case, if the treating physician is on vacation or unavailable, the practice needs a substitute physician who can administer the same level of care the treating physician would.
For example, if a patient were scheduled for chemotherapy via infusion (96410), the substitute physician may conduct his or her own brief exam and check the patient history (the correct E/M code is chosen based on the level of service). Although the substitute physician provided face-to-face care, and the staff provided care that was incident to the substitute's services, the treating physician is still entitled to bill for those services in the following manner:
96410-Q5 -- chemotherapy infusion, up to one hour; service furnished by a substitute physician under a reciprocal billing arrangement
99212-Q5 -- office or other [...]
