Don’t Let Locum Billing Make You Loco
When a physician fills in for another physician, avoid becoming denial crazy by following proper billing requirements.
Locum tenens is a physician who fills in for another physician for a period of 60 days or less. Here’s what you should know about locum tenens — or what the Medicare Claims Processing Manual, Transmittal 3774, refers to as Reciprocal Billing Arrangements — from a coding and billing perspective.
Reciprocal Billing Arrangements Are Relatively Uncommon
A “locum” is a person who temporarily stands in for someone else of the same profession. Merriam-Webster Dictionary gives us the following synonyms: backup, cover, designated hitter, fill-in, pinch hitter, relief, replacement, reserve, stand-in, sub, or substitute. Merriam-Webster also uses the term in a sentence: “I’m just a locum tenens, so any major decisions should be deferred until your regular doctor returns from vacation.”
A few examples of when it may be appropriate for a practice to hire locum tenens are:
- One of the physicians needs to take an extended time off, such as five weeks, due to a family emergency;
- A physician is going to take eight weeks of maternity leave;
- The physician is taking vacation; or
- One of the physicians is in the U.S. Army Reserves and has been called to active duty.
A locum arrangement is not something done regularly, or on a long-term basis, as explained in Transmittal 3774:
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,
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.
Requirements of Reciprocal Billing
Reciprocal billing is when a Medicare patient seeks to receive services from their regular physician, but their regular physician is unavailable and has arranged for a substitute physician in their absence. The regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment for covered visit services that the substitute physician provided.
Per Transmittal 3774, covered visit services include not only those services ordinarily characterized as covered physician visits, but also any other covered items and services furnished by the substitute physician or by others as incident-to the physician’s services. A continuous period of covered visit services begins on the first day the substitute physician provides covered visit services to the regular physician’s Medicare Part B patients and ends with the last day the substitute physician provides services to such patients before the regular physician returns to work.
This period continues without interruption on days no covered visit services are:
- Provided to patients on behalf of the regular physician; or
- Furnished by some other substitute physician on behalf of the regular physician.
A new period of covered visit services can begin after the regular physician has returned to work.
Modifiers Must Support Claims
To identify when reciprocal billing occurs, you must apply the appropriate modifier. Enter the modifier after the procedure code in the appropriate loop/segment that corresponds with Box 24 of the CMS-1500 claim form.
Modifier Q5 Service furnished by a substitute physician under a reciprocal billing arrangement is used for reciprocal billing under the same Employer Identification Number (EIN), also known as the Tax ID Number (TIN). It is used when a physician covers for another physician within the same group (both providers must be enrolled in Medicare).
Modifier Q6 Services furnished by a locum tenens physician is used for reciprocal billing when a substitute physician does not provide the visit/services to Medicare patients over a continuous period of longer than 60 days. The regular physician identifies the services as substitute physician, locum tenens, services with modifier Q6.
Medicare Administrative Contractor (MAC) Palmetto GBA further clarifies modifier Q6 use on their website.
Locum tenens background:
- Physicians may retain substitute physicians to take over their professional practices when they are absent for reasons such as illness, pregnancy, vacation, or continuing medical education.
- These substitute physicians, known as ‘locum tenens’ physicians, generally have no practice of their own and move from area to area as needed.
- The regular physician generally pays the substitute physician a fixed per diem amount. The substitute physician’s status is that of independent contractor, rather than employee, and his/her services are not restricted just to the physician’s office.
- Services of non-physician practitioners (e.g., CRNAs, NPs and PAs) may not be billed under the locum tenens or reciprocal billing reassignment exceptions. These provisions apply only to physicians.
Locum Tenens in Brief
Key take-aways for locum billing are:
- The regular physician must be unavailable.
- The substitute physician must only be filling in temporarily, which is defined as 60 days or less (with the one exception of physicians being called to active duty in the U.S. armed forces).
- Locum tenens billing can never be used for non-physician practitioners.
- The claim to the payer would identify the billing arrangement by using modifier Q6.
Palmetto GBA also explains the regular physician may submit a claim under the locum tenens arrangement using their own National Provider Identifier (NPI) and, if assignment is taken, receive payment for covered visit services if these conditions are met:
- The regular physician is unavailable to provide the visit/services.
- The Medicare patient has arranged or seeks to receive the visit/services from the regular physician.
- The regular physician pays the locum tenens physician for his/her services on a per diem or similar fee-for-time basis.
- The substitute physician does not provide the visit/services to Medicare patients over a continuous period of longer than 60 days.
- The regular physician identifies the services as substitute physician services with HCPCS modifier Q6 (services furnished by a locum tenens physician). Until further notice, the regular physician must keep on file a record of each service along with the substitute physician’s NPI.
- If postoperative services are furnished by the substitute physician, the services cannot be submitted with HCPCS modifier Q6 since the regular physician is paid a global fee.
- If services are provided by a substitute physician over a continuous period of longer than 60 days, the regular physician must submit the first 60 days with modifier Q6.
- The substitute physician must submit for the remainder of the services in his/her own name.
- The regular physician may not submit and receive direct payment for services over the 60-day period.
- A new period of covered visits can begin after the regular physician has returned to work.
The only exception to the 60-day limitation for locum tenens billing is when physicians are called to active duty in the U.S. Armed Forces for longer than the 60-day limitation.
Dr. Gone is taking a vacation to Europe for the month of July. Dr. Gone has arranged to have a substitute physician, Dr. Here, see patients in his absence. Dr. Here’s first day is July 2, and the first patient of the day is an established Medicare patient who presents complaining of a rash on her arms. Dr. Here sees the patient and determines that she has been in contact with poison oak, for which he advises the patient to purchase an over-the-counter ointment and apply as needed.
The claim would be submitted under Dr. Gone’s NPI, date of service 07/02/2018, place of service 11, 99213-Q6, diagnosis L23.7.
CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal, 3774, Change Request 10090: www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/r3774cp.pdf
Merriam-Webster, Definition of locum tenens:
MAC, Palmetto GBA, HCPCS Modifier Q6: