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CPT Code Modifiers: Q5 and Q6The HCPCS Medicare Level II Manual lists a group of modifiers that many medical coders do not regularly reference unless they are working in a specialized area. Some of these modifiers can be found in your current CPT Manual – although not all.

CPT Code Modifiers: Q5 and Q6

Two modifiers that generate from the HCPCS Manual are modifiers Q5 and Q6 which are associated with locum tenens and reciprocal billing arrangements. These modifiers should be used if the coder has a complete understanding of the practice’s situation in terms of physician coverage. (Not Physical Therapists or CRNAs)

Let’s begin with modifier Q6 which describes services furnished by a locum tenens physician.

A locum tenens physician is a substitute physician who takes over for an established doctor if he is absent for a period of sixty days or less and provides services to CMS Medicare patients. Some reasons for a physician being absent may be vacation time, disability, or pregnancy. Typically a locum tenens physician has no practice of his own and moves from one practice to another as needed. The absentee physician usually pays the substitute physician a fixed amount per diem. Simply stated, the locum tenens physician is considered an independent contractor.

So how do you code for a locum tenens doctor? A coder and biller will continue to bill Medicare under the regular physician’s provider id numbers (the absent physician). However, two things are very important to keep in mind and it is in everyone’s best interest to have a protocol set up with appropriate documentation in the event of an audit: (1) Add modifier Q6 in box 24 D after the CPT/HCPCS code. (2) In box 24J, the regular (absent) physician’s national provider id number must be indicated. The claim form will make clear the regular (absent) physician’s name and ID numbers, either as a solo practitioner or within a group practice, but the Q6 modifier alerts Medicare that another physician is covering for this doctor. Keeping a log to cross reference the coding/billing will also provide Medicare with information regarding the sixty (60) day limit of coverage. Most state Medicaid plans follow CMS guidelines, but it is always smart to contact your local carrier for specific information. Rules can vary among contracted HMO and PPO plans as well, so again, check your carriers for specific guidelines.

Modifier Q5 designates reciprocal billing arrangements where one physician covers for another physician on an occasional reciprocal basis. This physician is still considered a substitute physician and must be certified with a Medicare Part B carrier, and not be employed by the physician he or she is covering but he or she may have their own practice. As in locum tenens, a reciprocal billing physician cannot provide continuous coverage over a period of sixty days. Also, a reciprocal billing physician may have more than one arrangement with other physicians with no required contract. Reciprocal billing claims require modifier Q5 in box 24D after the CPT/HCPCS code and the regular (absent) physician’s national provider id numbers are used for billing in 24J.

For both locum tenens and reciprocal billing, modifiers Q5 and Q6 must be appended to each line of service.

For additional information regarding these rules, go to the Medicare Claims Processing Manual,
Chapter 1, Section 30.2.11.

You can view additional details online at: http:www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.

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2016-11-20T23:38:39+00:00

About the Author:

JoAnne Sheehan
JoAnne Sheehan has been successfully providing medical billing, coding and practice management services in the New England area for over thirty-three years. She has witnessed the evolution of healthcare and the increased complexities of medical billing and coding regulations, creating a need for education in this field. JoAnne has been featured in numerous medical publications and has acted as a medical billing expert in highly profiled Medicare and Medicaid fraud cases in Boston and has trained others on both a local and national level in medical billing and coding. She is a certified medical coding instructor, practice management consultant, and an AAPC approved ICD-10-CM instructor. Her hands-on experience is an asset for the CCO students she coaches. She is President and Founder of Lomar Associates, Inc., a practice management company established in 1981.

6 Comments

  1. Jen February 2, 2013 at 7:11 pm - Reply

    If there is a provider who is leaving a practice but remaining on payroll, is a Q5 modifier appropriate or acceptable to use for coverage by a locum withing the 60 day timeframe?

  2. teresa October 7, 2014 at 12:45 pm - Reply

    In your article you stated that you cannot use Q5 and Q6 for physical therapist, I have now been told three times by Medicare that we can use Q5 and Q6 for physical therapist.

    • JoAnne Sheehan, CPC, CPC-I, CPPM October 7, 2014 at 4:22 pm - Reply

      From what Medicare just told me; the only eligible providers for locums are medicine, osteopathy, podiatry,optometry,chiropractic, and dental surgery.
      Non-eligible providers are clinical nurse specialist,nurse anesthetist,nurse midwife, therapists:OT, PT,SLP,
      Psychologist and social worker.
      Typically I ask Medicare three times and go with a 2 out of 3 answer. In your case, it is 3 out of 3. What I would do in a case with conflicting information, I would do what my state’s Medicare tells me and monitor the reimbursements.
      Other carriers and Medicaid follow different rules. Medicare simply stated to me- “Locum Tenens is strictly for physicians”.
      If you have a physician providing a therapeutic modality, then yes, append the proper modifier.

      • Chris October 16, 2014 at 4:25 pm - Reply

        Hi JoAnne,

        Thanks for the article and info. I don’t think Teresa is going to respond to me, so have you ever heard of a MAC allowing a Q6 modifier with PT or OT? I have worked with Noridan, Trailblazer & Novitas in Colorado the past.
        Thanks for any info you might have.

        Chris

    • Chris October 13, 2014 at 2:50 pm - Reply

      Hi Teresa,

      I was trained all the way back in 2005 to use the Q6 for new PTs (and PTAs) when billing a DOS that had SOAP notes co-signed by a Medicare approved PT within the group, until the PT got a Medicare PTAN. Never had a problem until recently when I received a massive payment recoup notice (going back to some 2012 DOSs). 2 questions: What state are you in? and have you billed Medicare the Q6 for a PT yet?
      Thanks

      Chris

  3. Judy November 12, 2014 at 12:47 pm - Reply

    My Provider passed away and was told we should use Q5 modifier for Dr.’s that have been filing in to see Patients that are Medicare Providers have tryed billing several time not getting paid for these claims. not having issues with any other Insurance than Medicare. Any spoke to them with no help or answer. HElp!!!
    Judy

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