Oncology & Hematology Coding Alert

Answer: When the covering physician and the regular physician are in the same group practice, Medicare requires that the universal personal identification number (UPIN) of the physician who provided the service appear on the claim form. Each individual, therefore, should bill for the services provided.

Medicare law allows certain substitute billing arrangements under which Medicare will pay a physician who arranged to have another physician furnish services. The rules on substitute billing arrangements apply only when the substitute is not in the same group practice as the regular physician. If the regular physician and the covering physician are members of two distinct practices, Medicare will pay one physician for services furnished by a second if the following conditions are met:

The regular physician must be unavailable to provide the service.

The services must be furnished pursuant to an arrangement between the two physicians that is either 1) informal and reciprocal, or 2) involves per diem or other fee-for-time compensation.

Services cannot be provided by the substitute over a continuous period of more than 60 days.

The claim form submitted to Medicare must indicate that the claim meets the requirements listed above for payment to the regular physician. This is indicated by using the -Q5 modifier (services furnished by a substitute physician under a reciprocal billing arrangement) after the procedure code in Item 24D of the Health Care Financing Administration (HCFA) 1500 form. Use of the -Q5 modifier is an indication to Medicare that requirements for its use have been met.

The law requires that the UPIN of the substitute physician who provided the service be stated on the 1500 form, but there is no space for that entry now. Until the form is revised, Medicare requires that the regular physician keep a record of all services provided by a substitute together with the substitute physicians UPIN.

Editors note: This question was answered by Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H.