initial visit

If a specialist has already billed for an inital visit on a patient that he/she is following up on in the hospital and asked another physician of the same specialty but not from the same group to care for the patient while he/she is out of town, can that physician bill for an inital visit as well?

Reciprocal

An arrangement with other physicians to cover each other's practice on an occasional, as-needed basis, is known as a "reciprocal billing" arrangement. Reciprocal billing arrangements are often informal, and Medicare does not require them to be in writing. No money changes hands, and the regular physician compensates the covering physician by reciprocating in the future under similar circumstances. Billed in regular physicians name with Q5 modifier. No, the covering physician is taking the place of the regular physician who has already billed the Initial visit. Check to see if the reciprocal arrangement applies in your case.

on-call physician billing audit notice

More confusion. Please advise. PalmettoGBA Ohio just published in their Feb.2010 Medicare Advisory a notice from their auditors, Advancemed, entitled "ON-CALL PHYSICIANS" . The notice stated; "If you are billing for services rendered by another physician who is on-call using your own provider number, you are billing incorrectly. These services are to be submitted using the Provider Transaction Access Number (PTAN...) of the physician who actually rendered the service. We have identified providers (usually the patient's attending physician) that submit claims for services that are rendered by an on-call physician or a member of the same group practice. ....the audits have detected providers that use HPCPCS modifiers Q5...and Q6 incorrectly to identify services that are rendered by a covering physician but submitted to Medicare by the patient's attending physician who did not perform the service..... In conclusion, the provider community should submit claims for the services that the individual provider performs and the covering physician is to submit claims for the services that he/she performs".
We had for years a reciprocal billing arrangement as you described. As a result of this recent notice, we are now struggling to communicate with our 7 independent FP offices that cover for one another to determine each day's services for correct provider billing. Help!

Q5

We have identified providers (usually the patient’s attending physician) that submit claims for services that are rendered by an on-call physician or a member of the same group practice.
An "on call" physician is not same as Q5. Please refer to the Medicare Claims Processing Manual, Chapter 1, Sections 30.2.10 (Payment Under Reciprocal Billing Arrangements – Claims Submitted to Carriers) and 30.2.11 (Physician Payment Under Locum Tenens Arrangements – Claims Submitted to Carriers) for information concerning the proper use of HCPCS modifiers Q5 and Q6.
Also Carriers quote the rules: https://www.highmarkmedicareservices.com/refman/chapter-12.html#4
When the reciprocal billing arrangement guidelines are met, the service of the covering physician is billed with the Q5 modifier by the patients regular physician. The reciprocal billing arrangement guidelines are found in the Medicare Part A/B Reference Manual, Chapter 12.
I think it is the "on-call" term that is misleading. A Surgeon can be "on-call" for the emergency department but this is not Q5. I would confirm you meet all criteria for Q5 billing.

Q5 with AI

Thank you for the clarification. When the AI is appropriate for the admitting physician, which is the correct order for the AI and Q5 modifier?

Ai

In this scenario, you are saying the substitute physician is admitting the patient?
I thought the substitute physician was seeing the patient because the admitting physician had a reciprocal arrangement with physician of another practice to cover for him in his absence (ex, hospital visits)? In this case the regular physician already was admitting physician of record (AI) and the substitute would possibly cover subsequent hospital visit(s) for him, in his name with Q5. Maybe I misunderstood scenario.

weekend coverage

Our reciprocal agreement has been for weekend and vacation coverage. We have 7 FP docs in independent practices taking turns covering the weekends/vacations for each other. In this scenerio, the "on-call" or admitting physician is the covering (substitute) doctor who admits the patient on Sunday. The patient's regular physician takes over the patient's management on Monday. As they "reciprocate" services without any money changing hands, the regular physician bills for the admission (Sunday's) DOS also -- the AI modifier should go on Sunday's admission DOS with the Q5 following the AI?

Ai, q5

Sounds good. Be sure Q5 criteria is met.

Are you all sure?

I thought the reciprocal stuff was for locums doctors who are "hired" to see patients for a fixed period, not weekend visits.

Ooops- that's a Q6- found it.

But you are making this way complex- why not just bill for who you see???