Q&A: Locum Tenens Billing
Question: Our organization operates multiple sites throughout our state and often employs locum tenens to fill in for physicians. Can the organization bill for the locum tenens under another provider’s NPI number if that provider is not located at the site where the locum tenens is practicing? There is no practicing physician at the location where the locum tenens is working because the physician who will be taking over is awaiting credentialing.
Michael D. Miscoe JD, CPC, CASCC, CUC, CCPC, CPCO, CHCC responds:
Answer: Chapter 1, section 30.2.1.H of the Medicare Claims Processing Manual permits payment for services performed by a locum tenens provider to the patient’s regular physician during the absence of the regular physician, and where the regular physician pays the locum provider on a per diem/fee for time basis.
Further requirements are defined in section 30.2.11. Essentially, the regular physician must be temporarily unavailable (for no more than 60 days), for reasons such as illness, pregnancy, vacation, or attendance at CME training; the locum physician must not be an employee; the patient has already arranged or seeks to obtain care from the regular physician during the period of absence; and the service performed was one identified by the regular physician as a service that the substitute (locum) physician could perform.
As described by the question, the entity is using “locum” physicians as fill-in providers. The physician under whom they wish to bill does not appear to be the “regular physician,” and he/she is not “temporarily unavailable.” Because there is no “regular physician” who is temporarily unavailable due to infirmity, vacation, etc., the situation would not permit billing under the locum tenens rule. Moreover, a physician at another facility that does not work at the facility in question could not be considered the regular physician in the context of the locums rule because that physician is not “unavailable” for one of the permissible reasons.
To resolve the problem in the scenario described, a physician or NP/PA credentialed in the group must provide services at the facility in question. Assuming that person is a physician who is temporarily unavailable for one of the permissible reasons identified above, they could use a locum (who is not an employee, and who is paid on a per diem/pay for time basis) to fill in. Those services would be billed under the name and NPI of the regular physician who is temporarily unavailable, and for whom the locum is providing services. Such services would be billed with modifier Q6 Services furnished by a locum tenens physician.
To the extent that services were billed incorrectly, the entity should do a disclosure (voluntary) and refund monies improperly paid and received, in compliance with the reverse false claims provision of the False Claims Act. Failure to do so would result in those claims being deemed false claims, and FCA damages and penalties would apply.
Important! The locum tenens rule is a Medicare rule, and is applicable to Medicare and for physician services only. Be cautious when applying this concept to commercial payers. First, determine if the commercial payer being billed has adopted the Medicare locum tenens rule. In many commercial carrier cases where the service is performed by a non-credentialed physician—even a locum— it is not compensable. There is no such thing, even under Medicare, as a locum tenens NP or PA. The rule is not applicable to extenders or non-physician practitioners.
Latest posts by John Verhovshek (see all)
- Remember: CMS Allows ’97 Extended HPI with ’95 E/M Guidelines - December 5, 2016
- Code to the “Highest Severity” for Drug Use, Abuse, and Dependence - December 5, 2016
- HHS Warns of Phishing Attempt Disguised as Audit Communication - December 1, 2016