Q&A: Locum Tenens Billing

DoctorsQuestion: 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.


John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

5 Responses to “Q&A: Locum Tenens Billing”

  1. Kim says:

    Recently, our organization has started looking into using locum tennans providers however, there are a few questions unanswered.
    Per Medicare, the provider who saw the patient has to be the one sign off.
    This leads me to question, if the locum provider locks the note, it says electronically signed by (the locum providers name) but no actual signature is on the note, is that acceptable by Medicare or does the actual signature need to be on file?
    As far as scheduling appointments, does a schedule need to be built for the covering provider or is the schedule under the provider who is being covered for used?
    Also, as far as sending medications, I assume that has to be in the ordering physicians name (the locum provider) and not under the provider who they are covering for.
    I know these are basic questions but I am getting mixed information from different sources and need some advice.


  2. T.Thivierge says:

    I have had experience and read the guidelines for locum tenens billing. One thing keep in mind…the patient should really have had a face to face viewing with the Medicare network MD or attending physician . You should not use the locum tenens non-physician/allied clinician for a patient who has not had some type of face to face with a MD first or next few sessions. The care must be established with the MD at one time or place…..if not ensure the Medicare network physician signs off on same date of the patient’s session in the documentation. Also there needs to be an understanding with all physicians and or other allied clinicians this is occurring that the locum tenens billing regulation under Medicare. Also the medical record documentation must be reviewed by the MD with same date of visit for that patient experience locum tenens procedure. I have seen situations in which the attending physician has no idea this is happening under his or her name but service is just billed to Medicare. However if utilization review is required by some medical settings the doctors will pick up on this or when the Medicare RA is returned. Or if the patient is treated by a physician they have never met and this comes to the patient on Medicare EOB ….the patient may complain to Medicare agency.

    Kim’s question above….the EMR system could route the records of the Medicare patient using locum tenens to the attending Medicare network provider MD to review and authorize before the claim drops in the Medicare insurance bucket to bill. Set it up as authorization process for the non network Medicare clinicians can do the services ,but must be signed by Medicare network MD on same date of session so it will be billed. In other words set this up as a new edit under the Medicare billing. You could schedule the Medicare funded patient under the allied health clinician, but a flag would pop up for the claim to be fixed before it would be batched to bill to Medicare. Or create this special flag/edit on a report before bills are transmitted. Ensure the doc manually signs the same date of patient’s visit since under doc’s name to bill Medicare. If you try and transmit the Medicare claims using locum tenens process with allied clinician as only provider it will reject once hits Medicare’s doors. Also on the claim format CMS 1500 or 837p use the field 17 for the name of allied clinician not enrolled in Medicare who gave care for the Medicare patient to be pulled in on the claim. Also use the proper modifier showing locum tenens was completed in this scenario. Your computer staff/MIS folks should be able to hook this up for you or set it up. Or whoever has access to set up the provider programs linking to the specific insurance payers and the loop codes which correspond with the fields on the CMS 1500 claim format.

  3. Carol Roth says:

    I need to understand the 60 day rule better. we use locums in our office regularly for when one of our regular physicians is on vacation or out of the office. so, a locum may work 2 days in say April for a physician, our physician comes back but then goes on vacation again in September and that same locum works again for a whole week.
    does that 60 days restart in September?

  4. maria says:

    one of our doctors terminated his employment. Can a locum be used in his absence and bill Medicare?

  5. Aimee Cutter says:

    Carol Roth – yes the 60 days will restart when the locums returns in September.

    Maria – yes, for 60 consecutive days. That being said the clock started ticking the first day after the physician’s departure. Additionally, if the physician terminated their benefits with your group then the Q6 modifier would no longer be applicable.

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