CMS Pub. 100-04, ch. 1, § 30.2.10

Submitted to A/B MACS Part B

(Rev. 3774, 05-12-17, Effective: 06-13-17, Implementation: 06-13-17)

A. General requirements applicable to all Reciprocal Billing Arrangements

Under section 16006 of the 21st Century Cures Act, a Medicare-enrolled physical

therapist may use a substitute physical therapist to furnish outpatient physical therapy

services in a HPSA, a MUA, or a rural area under a reciprocal billing arrangement on or

after June 13, 2017.

The patient’s regular physician or physical therapist may submit the claim, and (if

assignment is accepted) receive the Part B payment, for covered visit services which the

regular physician or physical therapist arranges to be provided by a substitute physician

or physical therapist on an occasional reciprocal basis, if:

• The regular physician or physical therapist is unavailable to provide the services;

• The Medicare patient has arranged or seeks to receive the services from the

regular physician or physical therapist;

• The substitute physician or physical therapist does not provide the services to

Medicare patients over a continuous period of longer than 60 days subject to the

following exception: A physician or physical therapist called to active duty in the

Armed Forces may bill for services furnished under a reciprocal billing

arrangement for longer than the 60-day limit; and

• The regular physician or physical therapist indicates that the services were

provided by a substitute physician or physical therapist under a reciprocal billing

arrangement meeting the requirements of this section by entering in item 24d of

Form CMS-1500 HCPCS code Q5 modifier (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) after the procedure code. The

regular physician or physical therapist must keep on file a record of each service

provided by the substitute physician or physical therapist along with the

substitute physician or physical therapist’s NPI, and make this record available to

the A/B MAC Part B upon request.

If the only services a physician performs in connection with an operation are post-operative services furnished during the period covered by the global fee, these services

need not be identified on the claim as services furnished by a substitute physician.

A physician or physical therapist may have reciprocal billing arrangements with more

than one physician or physical therapist. The arrangements need not be in writing.

With respect to physicians, the term “covered visit service” includes not only those

services ordinarily characterized as a covered physician visit, but also any other covered

items and services furnished by the substitute physician or by others as “incident to” the

physician’s services.

With respect to physical therapists, the term “covered visit service” means outpatient

physical therapy services furnished in a HPSA, a MUA, or a rural area. HPSAs and

MUAs are designated by the Health Resources & Services Administration (HRSA). To

determine if an area is a HPSA or an MUA, visit HRSA’s website at

https://www.hrsa.gov. A rural area is any area that is outside of a Metropolitan Statistical

Area or a Metropolitan Division (in the case where a Metropolitan Statistical Area is

divided into Metropolitan Divisions), as defined by the Executive Office of Management

and Budget, or the following New England counties: Litchfield County, Connecticut;

York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire;

and Newport County, Rhode Island. To determine if an area is rural, consult the

Crosswalk of Counties to Core-Based Statistical Areas in the most current Inpatient

Prospective Payment system final rule. Any area that is not designated as urban in the

crosswalk is rural.

A “continuous period of covered visit services” begins with the first day on which the

substitute physician or physical therapist provides covered visit services to Medicare Part

B patients of the regular physician or physical therapist, and ends with the last day the

substitute physician or physical therapist provides services to such patients before the

regular physician or physical therapist returns to work. This period continues without

interruption on days on which no covered visit services are provided to patients on behalf

of the regular physician or physical therapist or are furnished by some other substitute

physician or physical therapist on behalf of the regular physician or physical therapist.

A new period of covered visit services can begin after the regular physician or physical

therapist has returned to work.

EXAMPLE: The regular physician or physical therapist goes on vacation on June 30,

and returns to work on September 4. A substitute physician or physical therapist

provides services to Medicare Part B patients of the regular physician or physical

therapist on July 2, and at various times thereafter, including August 30 and September 2.

The continuous period of covered visit services begins on July 2 and runs through

September 2, a period of 63 days. Since the September 2 services are furnished after the

expiration of 60 days of the period, the regular physician or physical therapist is not

entitled to bill and receive direct payment for the services furnished August 31 through

September 2. The substitute physician or physical therapist must either bill for the

services furnished August 31 through September 2 in his/her own name and billing

number or reassign payment to the person or group that bills for the services of the

substitute physician or physical therapist. The regular physician or physical therapist

may, however, bill and receive payment for the services that the substitute physician or

physical therapist provides on behalf of the regular physician or physical therapist in the

period July 2 through August 30.

The requirements for the submission of claims under reciprocal billing arrangements are

the same for assigned and unassigned claims.

A/B MACs Part B should inform physicians and physical therapists of the compliance

requirements when billing for services of a substitute physician or physical therapist. The

physician or physical therapist notification should state that, in entering the Q5 modifier,

the regular physician or physical therapist (or the medical group or physical therapy

group, where applicable) is certifying that the services are covered visit services

furnished by the substitute physician or physical therapist identified in a record of the

regular physician or physical therapist which is available for inspection, and are services

for which the regular physician or physical therapist (or group) is entitled to submit the

claim. A/B MACs Part B should include in the notice that penalty for false certifications

may include civil or criminal penalties for fraud, or administrative penalties including

revocation of the physician’s or physical therapist’s Medicare billing privileges, right to

receive payment, or to submit claims or accept any assignments. The revocation

procedures are set forth under 42 CFR 424.535 and in the Medicare Program Integrity

Manual (Pub. 100-8).

If a line item includes the code Q5 certification, A/B MACs Part B assume that the claim

meets the requirements of this section in the absence of evidence to the contrary. A/B

MACs Part B need not track the 60-day period or validate the billing arrangement on a

prepayment basis, absent postpayment findings that indicate that the Q5 certifications by

a particular regular physician or physical therapist may not be valid.

When A/B MACs Part B make Part B payment under this section, they determine the

payment amount as though the regular physician or physical therapist provided the

services. The identification of the substitute physician or physical therapist is primarily

for purposes of providing documentation to verify upon audit that the services were

actually furnished, not for purposes of the payment or the limiting charge. Also, notices

of noncoverage are to be given in the name of the regular physician or physical therapist.

B. Requirements applicable to Physician Medical Group or Physical Therapy

Group Claims Under Reciprocal Billing Arrangements

In order for a medical group or physical therapy group to submit claims in the name of

the regular physician or physical therapist for the services of a substitute physician or

physical therapist, the substitute physician or physical therapist may not have reassigned

his or her right to Medicare payment to the group through a CMS-855R reassignment

enrollment form approved by the A/B MACs Part B and the following requirements must

be met:

• The regular physician or physical therapist is unavailable to provide the services;

• The Medicare patient has arranged or seeks to receive the services from the

regular physician or physical therapist; and

• The substitute physician or physical therapist does not provide the services to

Medicare patients over a continuous period of longer than 60 days subject to the

following exception: A physician or physical therapist called to active duty in the

Armed Forces may bill for services furnished under a reciprocal billing

arrangement for longer than the 60-day limit.

Services are billed for the entity as follows:

• The medical group or physical therapy group must enter in item 24d of Form

CMS-1500 the HCPCS code modifier Q5 after the procedure code.

• The designated attending physician for a hospice patient (receiving services

related to a terminal illness) bills the Q5 modifier in item 24 of Form CMS-1500

when another group member covers for the attending physician.

• A record of each service provided by the substitute physician or physical therapist

must be kept on file along with the substitute physician’s or physical therapist’s

NPI. This record must be made available to the A/B MAC Part B upon request.

• In addition, the medical group physician or group physical therapist on whose

behalf the services were furnished by a substitute must be identified by his/her

NPI in block 24J of the appropriate line item.

On claims submitted by a group, the group physician or group physical therapist who

actually performed the service must be identified in the manner described in §30.2.13,

with one exception. When a group member provides services on behalf of another group

member who is the designated attending physician for a hospice patient, the Q5 modifier

may be used by the designated attending physician to bill for services related to a

hospice patient’s terminal illness that were performed by another group member.