Compliant billing: Using the right modifier

Electronic Health Records (EHRs) and their impact on healthcare has been a hot topic in recent months and large EHR providers are finding themselves facing charges of fraud for upcoding and non-compliance. This puts urgent care clinics and their software providers under a microscope when it comes to billing practices.

One of the most confusing billing aspects for many clinics is understanding when it’s okay to bill under another physician’s National Provider Identifier (NPI) number, and more importantly, when it’s not.

There are only two circumstances when a physician can bill under another physician’s NPI. Both of these arrangements apply to physicians only.

Fee-For-Time Compensation Arrangements – Q6 Modifier

Formerly referred to as Locum Tenens, this is the arrangement in which a regular physician hires a substitute physician to take over his practice due to an extended absence. The substitute physician operates as an independent contractor. The regular physician pays the substitute on a per diem or fee-for-time compensation basis.

The regular physician bills for the substitute physician’s services with a Q6 modifier.

This modifier identifies service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area.

The following requirements must be met:

• The regular physician is unavailable to provide the services
• The patient has arranged or seeks to receive the services from the regular physician
• The substitute physician does not provide the services to patients over a continuous period of longer than 60 days
• The regular physician keeps on file a record of each service provided by the substitute physician along with the substitute physician and make this record available to the payer upon request
• The regular physician pays the substitute for his/her services on a per diem or similar fee-for-time basis

If the substitute physician is an employee of the practice, this billing arrangement is not appropriate.

In a group practice, the substitute physician may not have reassigned their rights for payment to the group.

Reciprocal Billing Arrangements – Q5

In this arrangement, two physicians cover each other’s patients when one of the physicians is unavailable. The regular physician bills for the substitute physician’s services with a Q5 modifier.

This modifier identifies service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area.

This arrangement is described as “occasional” and must meet the same requirements as Fee-for-Time compensation arrangements with the exception that there are no payment terms.

An example of this is when the regular physician goes on vacation and asks a colleague to cover his patients. The colleague would not be a member of the regular physician’s group practice. For government payers, the substitute physician needs to be an approved provider with the plan, albeit under their own practice. This is a more casual arrangement without a payment exchange between physicians.

What is incident-to billing?

This is a method of billing for incidental services performed by mid-levels and nonphysician employees in accordance with the physician’s treatment plan. It does not apply between physicians.

Incident-to billing applies to established patients with an existing treatment plan that is not deviated from. It is extremely rare in the urgent care setting.

Be sure everyone on your team knows when this method of billing is appropriate.

Accuracy is essential to compliance.

For government payers, physicians in a group practice are required to bill with their own provider numbers.

For faster reimbursement, it can be tempting for urgent care groups to submit claims under a credentialed physicians name until a rendering physician can be properly credentialed. There’s no compliant way to speed up the claims process in this situation.

Don’t take unnecessary risks. Use your Q5 and Q6 modifiers appropriately – and wisely.