July 17th, 2015
The patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:
• 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 subject to the exception noted below; and
• The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering in item 24d of Form CMS-1500 HCPCS code Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement) after the procedure code. When Form CMS-1500 is next revised, provision will be made to identify the substitute physician by entering the unique physician identification number (UPIN) or NPI when required on the form and cross-referring the entry to the appropriate service line item(s) by number(s). Until further notice, the regular physician must keep on file a record of each service provided by the substitute physician, associated with the substitute physician’s UPIN or NPI when required, and make this record available to the carrier upon request.
EXCEPTION: In accordance with section 116 of the “Medicare, Medicaid, and SCHIP Extension Act of 2007” (MMSE), enacted on December 29, 2007, the exception to the 60-day limit on substitute physician billing for physicians called to active duty in the Armed Forces has been extended for services furnished from January 1, 2008 through June 30, 2008. Thus, under this law, a physician called to active duty may bill for substitute physician services furnished from January 1, 2008 through June 30, 2008 for longer than the 60-day limit.
If the only substitution services a physician performs in connection with an operation are post-operative services furnished during the period covered by the global fee, these services need not be identified on the claim as substitution services.
A physician may have reciprocal arrangements with more than one physician. The arrangements need not be in writing.
The term “covered visit service” includes not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as incident to the physician’s services.
“Incident to” services furnished by staff of a substitute physician or regular physician are covered if furnished under the supervision of each.
A “continuous period of covered visit services” begins with the first day on which the substitute physician provides covered visit services to Medicare Part B patients of the regular physician, and ends with the last day the substitute physician provides services to these patients before the regular physician returns to work. This period continues without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or are furnished by some other substitute physician on behalf of the regular physician. A new period of covered visit services can begin after the regular physician has returned to work.
EXAMPLE: The regular physician goes on vacation on June 30, and returns to work on September 4. A substitute physician provides services to Medicare Part B patients of the regular physician on July 2, and at various times thereafter, including August 30 and September 2. The continuous period of covered visit services begins on July 2 and runs through September 2, a period of 63 days. Since the September 2 services are furnished after the expiration of 60 days of the period, the regular physician is not entitled to bill and receive direct payment for them. The substitute physician must bill for these services in his/her own name. The regular physician may, however, bill and receive payment for the services that the substitute physician provides on his/her behalf in the period July 2 through August 30.
The requirements for the submission of claims under reciprocal billing arrangements are the same for assigned and unassigned claims.
A. Physician Medical Group Claims Under Reciprocal Billing Arrangements
The requirements of this section generally do not apply to the substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group. On claims submitted by the group, the group physician who actually performed the service must be identified in the manner described in §30.2.13 with one exception. When a group member provides services on behalf of another group member who is the designated attending physician for a hospice patient, the Q5 modifier may be used by the designated attending physician to bill for services related to a hospice patient’s terminal illness that were performed by another group member.
patient’s terminal illness that were performed by another group member. For a medical group to submit assigned and unassigned claims for the covered visit services of a substitute physician who is not a member of the group and for an independent physician to submit assigned and unassigned claims for the substitution services of a physician who is a member of a medical group, the following requirements must be 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; and
• The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days.
Substitute billing services are billed for each entity as follows:
• The medical group must enter in item 24d of Form CMS-1500 the HCPCS code modifier Q5 after the procedure code.
• The independent physician must enter in item 24 of Form CMS-1500 HCPCS code modifier Q5 after the procedure code.
• The designated attending physician for a hospice patient (receiving services related to a terminal illness) bills the Q5 modifier in item 24 of Form CMS-1500 when another group member covers for the attending physician.
• A record of each service provided by the substitute physician must be kept on file and associated with the substitute physician’s UPIN or NPI when required. This record must be made available to the carrier upon request.
• In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her provider identification number (PIN) or NPI when required in block 24J of the appropriate line item.
Physicians who are members of a group but who bill in their own names are treated as independent physicians for purposes of applying the requirements of this section.
Carriers should inform physicians of the compliance requirements when billing for services of a substitute physician. The physician notification should state that, in entering the Q5 modifier, the regular physician (or the medical group, where applicable) is certifying that the services are covered visit services furnished by the substitute physician identified in a record of the regular physician which is available for inspection, and are services for which the regular physician (or group) is entitled to submit the claim. Carriers should include in the notice that penalty for false certifications may be civil or criminal penalties for fraud. The physician’s right to receive payment or to submit claims or accept any assignments may be revoked. The revocation procedures are set forth in §40.
If a line item includes the code Q5 certification, carriers assume that the claim meets the requirements of this section in the absence of evidence to the contrary. Carriers need not track the 60-day period or validate the billing arrangement on a prepayment basis, absent postpayment findings that indicate that the certifications by a particular physician may not be valid.
When carriers make Part B payment under this section, they determine the payment amount as though the regular physician provided the services. The identification of the substitute physician is primarily for purposes of providing an audit trail to verify that the services were furnished, not for purposes of the payment or the limiting charge. Also, notices of noncoverage are to be given in the name of the regular physician.