HCPCS Modifier Q5

Description
Services furnished by a substitute physician under a reciprocal billing arrangement.

Guidelines/Instructions
  • Submit HCPCS modifier Q5 to indicate that services were provided under a reciprocal billing arrangement
Reciprocal Billing Background
On an occasional reciprocal basis, a patient's regular physician will arrange for a substitute physician to provide visit/services, including emergency visits or related services. Under a reciprocal billing arrangement, the patient's regular physician may submit a claim to Medicare Part B using his/her own National Provider Identifier (NPI) and, if assignment is accepted, receive payment if the following conditions are 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
  • The substitute physician does not provide the visit/services to Medicare patients over a continuous period of longer than 60 days
  • The regular physician identifies the services as substitute physician services by using HCPCS modifier Q5 (services furnished by a substitute physician under a reciprocal billing arrangement)
  • Until further notice, the regular physician must keep on file a record of each service provided by the substitute physician along with the substitute physician's National Provider Identifier (NPI)
Exception to the 60-day limitation for reciprocal billing:
  • Section 116 of the Medicare, Medicaid and SCHIP Extension Act of 2007 extended the exception to the 60-day limit on substitute physician billing for physicians being called to active duty in the armed forces for services furnished from January 1, 2008, through June 30, 2008. Section 116 of Public Law 110-173 extended the accommodation of physicians ordered to active duty in the Armed Forces, enacted by Public Law 110-54, by striking January 1, 2008, and inserting July 1, 2008.
  • Essentially, both legislative acts allow a physician being called to active duty to bill for the services furnished by a substitute physician for longer than the 60-day limitation
If postoperative services are furnished by the substitute physician, the services cannot be submitted with HCPCS modifier Q5 since the regular physician is paid a global fee.
  • If services are provided by a substitute physician over a continuous period of longer than 60 days, the regular physician must bill the first 60 days with HCPCS modifier Q5 (services furnished by a substitute physician under a reciprocal billing arrangement)
  • The substitute physician must submit the remainder of the services in his/her own name
  • The regular physician may not submit and receive payment for services over the 60-day period
  • A new period of covered visit/services can begin after the regular physician has returned to work
Reference: CMS Pub. 100-04, Chapter 1, Section 30.2.1.H and 30.2.10 (PDF, 4.28 MB).

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