CODING & DOCUMENTATION

Most Medicare and Medicaid plans will allow you to cover another physician's practice under an arrangement known as reciprocal billing. Private payers' policies may differ, so verify the policies of your most common payers before reporting reciprocal billing. Here is how it works:The absent physician may bill as if he or she provided the service. He or she must be unavailable to provide the care, the patient must request the care, and the documentation of services provided must be maintained by the absent physician's practice. HCPCS modifier Q5, “Service furnished by a substitute physician under a reciprocal billing arrangement,” should be appended to all of the procedure codes reported.A physician cannot provide services under a reciprocal billing agreement for a continuous period of longer than 60 days. Also note that patients cared for under a reciprocal billing agreement may not be considered new patients for coding purposes if they would be an established patient to the absent physician. For these reasons, many physicians do not use the reciprocal billing arrangement, instead choosing to treat all patients who would normally receive care from the absent physician as their own patients and coding accordingly.

If any sign or symptom of illness or injury is present, you should submit the ICD-10 code for the sign or symptom. Alternatively, the ICD-10 manual includes observation codes that can be reported for a patient who has no signs or symptoms of illness or injury but requires examination and observation for a suspected condition that is ultimately ruled out. ICD-10 codes included in category Z04 are used to report examination and observation that rules out illness or injury following accidents. For example, if you find that a patient has no injury and no signs or symptoms of injury after being struck by a baseball, you would report code Z04.3, “Encounter for examination and observation following other accident.” External cause codes may also be reported to indicate the nature of patient presentation (e.g., W21.03XA, “Struck by baseball, initial encounter”).

Medicare will pay the same amount whether the procedure was performed unilaterally or bilaterally. You may bill code 69210, “Removal impacted cerumen requiring instrumentation, unilateral,” with modifier 50 added to indicate that the procedure was performed bilaterally, but the Medicare physician fee schedule indicates this procedure is ineligible for additional payment.