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If you take a little time to understand Medicare's requirements for reciprocal billing of substitute care, you'll be rewarded.

Fam Pract Manag. 2000;7(6):14

You've planned your summer vacation, and everything is in order. You've booked your hotel room and stopped the mail. You've even arranged for a colleague to see your patients in your absence. Wouldn't it be nice to get paid for those visits? Under the right circumstances, Medicare will reimburse you. Here's what you need to know.

What are Medicare's parameters?

You may submit claims and receive payments from Medicare for covered visit services, including emergency visits and related services, that you arrange to be provided by a substitute physician on an occasional, reciprocal basis. The following four requirements must be met:

  • You must be unavailable to provide the visit services.

  • The Medicare patient must have arranged to receive or seek to receive the visit services from you.

  • The substitute physician must not provide the visit services to Medicare patients over a continuous period of more than 60 days.

  • You must submit the claim using your unique physician identification number (UPIN) and attach a -Q5 modifier to the procedure code. Also be sure to cross-reference the entry to the appropriate service line item.

Of course, if you are in a group practice where claims are submitted in the name of the group, then reciprocal billing does not apply to you. If you are a member of a group whose physicians bill in their own names, then Medicare treats you as an independent physician, and the rules regarding reciprocal billing arrangements apply.

Documenting the care

Maintain a record of each service provided by the substitute physician, including a reference to the substitute physician's UPIN. This file should be made available to your Medicare carrier upon request.

If the only substitute services a physician performs in connection with an operation are postoperative services furnished during the period covered by the global fee, you need not identify these on the claim as substitution services.

Reciprocal arrangements need not be in writing, and you may have arrangements with more than one physician. All reciprocal arrangement requirements are the same for assigned and unassigned claims.

What about locum tenens?

The requirements for claiming payment for locum tenens' services are almost the same as those for reciprocal billing arrangements. The only differences are that you have to use a -Q6 modifier and you must pay the locum tenens physician on a per diem or fee-for-time basis. Locum tenens physicians cannot be your employees, and their patient services cannot be restricted to your office.

You're on your way

Now load up the car, and turn off your pager. You can hit the road knowing that if you have a reciprocal billing arrangement in place, your Medicare payments will continue to come in, even in your absence.

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