Ask the Coding Experts

Reciprocal billing of fee-for-time

Q: Our practice has been billing a fill-in provider as a locum tenens. We recently decided to get her credentialed. All but one insurance has approved. Aetna is not accepting new providers at this time and did not approve her. My question is: can we continue to bill Aetna as a locum tenens like we have, or do we have to refrain from booking Aetna patients with her for future appointments? 

A: We strongly suggest you contact Aetna to ensure what they will or will not allow for locum tenens (now referred to as reciprocal billing of fee-for-time) and for how long.  

There is a 60-day limited duration of billing privileges (prior to enrollment), and the Q5 or Q6 modifier (as appropriate) is appended to each line of service performed by the substitute provider. The same temporary doctor can substitute for each one of your regular staff docs concurrently but would still be subject to the 60-day duration of the locum tenens arrangement for each provider. 

The individual NPI number of the substitute physician should be entered into Box 24J of the CMS 1500 Form. The practice has the option to enroll the temporary doctor with your Medicare Carrier (MAC) if he/she decides to work for your group on an ongoing limited basis beyond the 60-day time frame. 

Required Modifiers for Reciprocal Billing or Fee-for-Time Arrangements 

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 

Q6 Modifier: 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 

References: 

1. CMS reference p10-12: https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/r3774cp.pdf 

2. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf

3. https://www.aapc.com/blog/27489-bill-locum-tenens-according-to-cms-guidelines/?srsltid=AfmBOoqRCRD6jM0g9_aCNW_aR4PmP3YS8tsTS5KsdruNjNUB00zsIdrK

4. Palmetto GBA: https://palmettogba.com/jmb/did/p6l8d11pxh

5. NGS: https://www.ngsmedicare.com/web/ngs/billing?selectedArticleId=438511&lob=96664&state=97178&rgion=93623 

6. Novitas: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00105762 

Aetna addresses the use of Modifier Q5 and Q6 in their manual 

P67 https://www.aetna.com/document-library/health-care-professionals/office-manual-hcp.pdf 

Modifier -25 

Q: I know you’re not allowed to bill E&M the same day with a procedure unless they are for totally different reasons (i.e. -25 modifier). My question is: If you do both, is there something that obligates you to choose one vs. the other? Ideally, I’d like something authoritative if so. 

Case in point: A patient comes in with a complaint of irritation/pain. I must evaluate to determine a diagnosis and then set up a management plan—all of which is E&M. If the diagnosis ends up being trichiasis and I decide a minor procedure (epilation) is needed, is there a CMS policy or some general AMA requirement that I MUST bill the epilation instead of billing the E&M that was necessary to determine that the epilation was warranted? The same could be said of foreign body removal. 

I want to avoid being accused of upcoding; generally, I’ve always assumed I could just code the office visit and not bill the epilation (because the epilation reimburses so little). Recently someone told me I’m supposed to bill the epilation. This didn’t make sense because it’s not like other minor procedures where it’s planned in advance and the diagnosis is known—having them come back the next day to do a planned minor procedure seems silly (though admittedly I imagine that’s likely how most minor procedures probably get planned/billed by other professions; when there isn’t an established diagnosis, an office visit is initially performed to determine it and the decision for surgery is part of that office visit). 

A: Thank you for your question. This is one that many doctors ponder. HIPAA says you must use the most appropriate code for the service provided. The codes are described by CPT. Medicare usually follows CPT advice and direction. So, Medicare will expect providers to use the most appropriate code for the service they are providing. 

To bill an E&M with the epilation with forceps code, 68720, the provider would need to use the 25 modifier with the E&M service code. When using this modifier, the provider is stating that the purpose of the visit was initiated for some reason other than trichiasis but finds trichiasis in the course of the exam and also bills epilation. 

For example, if the established patient is scheduled for a problem-oriented office visit and you find trichiasis is the source of an additional problem, you might bill an E&M with a 25 modifier and the 67820 epilation code. If the reason for the problem-oriented visit is trichiasis only, then bill the epilation procedure code. It is important to understand; the epilation code has a small amount of work value (partial E&M) built into the code. If the patient is new to the practice and comes in with an unknown problem and you find trichiasis, then an E&M code without any modifier can be billed in addition to the epilation.

The new CMS G2211 code

Q: There was a webinar that was put on by the Third Party Center Committee that included updates on the use of this code [G2211]. I can't seem to locate it on the AOA website. Was that recorded? I understand the definition of the code per the CPT book, but I was hoping to review the webinar to better understand some of the nuances to the code. I'm being asked if it can be used to follow strabismus/amblyopia and I have some reservations considering in the Medicare population, amblyopia would be a chronic condition and not really need "complex" care.

A: Read the AOA’s article “Introducing the new CMS G2211 code.”

Access the webinar reviewing all changes for 2025, which discusses G2211.

The primary component is the chronicity of the problem and that the doctor is managing it.  Diabetes and hypertension, while chronic, are not typically managed by the optometrist. Glaucoma, vision loss from ARMD, and dry eye would be better examples. Typically, unless strabismus was a result of something such as a stroke, closed head injury or diabetes, a long-standing stable condition would most likely not qualify. Certainly, in a Medicare patient who had the condition since childhood, it would most likely not be justified.

CMS definition of G2211: Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)

Q: I need help with clarification on use of G2211. There is a lot of confusion and differing opinions on when it should be used. Can it be used for all chronic disease I may be following such as dry eye disease, diabetics, AMD, hypertension, etc.? I have seen that it should not be used on more than 10% of your 99xxx codes or will flag an audit.

A: CMS states, “The complexity is in the cognitive load of the continued responsibility of being the focal point for all needed services for the patient. There’s important cognitive effort of using the longitudinal doctor-patient relationship itself in the diagnosis and treatment plan. These factors, even for a simple condition … make the entire interaction inherently complex.” CMS makes it clear that the patient condition itself does not necessarily indicate how complex the care might be.

We have not heard of any thresholds or red flags on the use of this code at this time.

Helpful resources:

• Article: Introducing the new CMS G2211 code
• Webinar: ICD-10-CM, CPT® and Other Changes for 2025 (slides 55-56)
• CMS G2211 FAQs
• CMS MedLearn Matters on G2211
• CMS Transmittal 12461 on G2211

Code 82948: Checking blood sugar

Q: My doctors have a question about blood draw checking blood sugar code 82948. Is this the correct code for them to bill? They are having a hard time finding it on the Medicare billing site. 

A: AOA Coding Today is a great place to look up code definitions.    

CPT 82948 CPT Full Definition 

Description: 

Glucose; blood, reagent strip (Source: 2025 CPT®) 

Lay Description 

A blood sample is taken and the amount of glucose in the bloodstream is measured. The test is performed by placing a drop of blood on a reagent strip, which is a piece of paper that changes color based on the glucose level of the blood. 

Note that Clinical Laboratory Improvements Amendments (CLIA) require anyone performing this test to have an appropriate certificate. This is not a “CLIA waived” test.  To learn more about CLIA certificates, see https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/howobtaincliacertificate.pdf 

The pay amount is national, and it is listed as: 

Clinical Lab Fees 

Clinical Diagnostic Laboratory (National Limit): $5.04 (5.04) (which you can also find on AOA Coding Today). Keep in mind that other than the laboratory codes, the fee will vary slightly by location. 

Under CPT Full Definition it reads as follows: 

CPT Notes 

Pathology and Laboratory > Chemistry 

Chemistry 

The material for examination may be from any source unless otherwise specified in the code descriptor. When an analyte is measured in multiple specimens from different sources, or in specimens that are obtained at different times, the analyte is reported separately for each source and for each specimen. The examination is quantitative unless specified. To report an organ or disease-oriented panel, see codes 80048-80076. 
 
Clinical information or mathematically calculated values, which are not specifically requested by the ordering physician and are derived from the results of other ordered or performed laboratory tests, are considered part of the ordered test procedure(s) and therefore are not separately reportable service(s). 
 
When the requested analyte result is derived using a calculation that requires values from nonrequested laboratory analyses, only the requested analyte code should be reported. 
 
When the calculated analyte determination requires values derived from other requested and nonrequested laboratory analyses, the requested analyte codes (including those calculated) should be reported. 
 
An exception to the above is when an analyte (e.g., urinary creatinine) is performed to compensate for variations in urine concentration (e.g., microalbumin, thromboxane metabolites) in random urine samples; the appropriate CPT code is reported for both the ordered analyte and the additional required analyte. When the calculated result(s) represent an algorithmically derived numeric score or probability, see the appropriate multianalyte assay with algorithmic analyses (MAAA) code or the MAAA unlisted code (81599).  

How the coding of an encounter can change

Q: If a patient presents for new onset floaters and/or flashes and dilated exam finds a posterior vitreous detachment but no retinal defects and no other complaints that needed to be addressed at this encounter, I assume that’s level four complexity (1 undiagnosed new problem with uncertain prognosis, as we don’t know if it will lead to retinal defects as PVD progresses) but a level three risk (since not prescribing meds or decision regarding major surgery). So, if billing an E&M code, a 99203 or 99213 service would describe the encounter, correct?

A: We agree that you are meeting the moderate level on the number of or complexity of problems addressed for the reason you cited. If the encounter were to end at this juncture with relatively low risk of grave complication, then a level three service would be appropriate. 

Q: Same patient with a twist: You offer a surgical consult for vitrectomy because of how bothersome and visually disturbing the floater is, but the patient declined surgical referral. Would that increase the risk to level four and, therefore, the code to 99204 or 99214? 

A: CPT has stated that circumstances sufficiently complex as to require a referral/ consultation or prescription medications, even if the patient chooses not to follow the recommended course of action, meet the requirements of the moderate risk category.  Because both the complexity of the presenting problem and the risk of complications are moderate, then scenario two does meet the level four standard as long as all components are documented. 

Q: Same patient and clinical sequence as the first scenario except the patient reports blurred vision that was present well before the posterior vitreous detachment symptoms. You identify the posterior vitreous detachment with no retinal defect and also discover moderate cataract formation for which you discuss possible referral for cataract surgery. However, the patient declines the surgical referral. Does that still push the risk to level four, and, therefore, the code to 99204 or 92014? 

A: By the same reasoning as applied above, the third scenario remains at level four as long as all components are documented. A moderate complexity problem exists that presents a moderate risk of morbidity to the patient despite the patient’s reluctance to proceed with surgery at this time. 

It appears in all three scenarios that you have conducted and met the criteria of a comprehensive eye examination (92004 or 92014), so billing this option is available. There is also the possibility that the second or third scenarios may involve considerable time in counseling the patient about the presenting condition and the treatment options, so selecting the E/M based upon time remains an option. The total time on the date of service must exceed 30 minutes for a 99214 for the established patient and 45 minutes for a new patient encounter 99204. 

The coding of an encounter does change based not only upon the presenting condition of the patient but also upon the amount and complexity of data to be reviewed, your management approach and recommendations, as well as the relative risk of morbidity or risk to the organ or sight of the patient.  2024 evaluation and management chart.docx