Medicare Compliance & Reimbursement

Watch the NPI rules.

Doctors go on vacations, have family emergencies, and get sick just like everyone else. Substituting another physician under one of the two billing option can be tricky. Pocket this quick go-to for the top takeaways and nuances separating locum tenens (LT) and reciprocal billing.

Locum tenens fundamentals: LT describes a one-way exchange between providers. For this type of billing situation, a physician would retain a substitute physician to take over the practice for such reasons as illness, pregnancy, vacation, or continuing medical education. The substitute physician or LT generally is paid a fixed amount per diem or similar for-time basis.

To report the LT services, you would append modifier Q6 (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) to all of the temporary physician's claims, but bill under the replaced physician's National Provider Identifier (NPI).

Reciprocal billing essentials: This style of arrangement is a two-way exchange and utilizes a different modifier. For example, your physician and another doctor agree to see each other's patients on weekends off and agree to a reciprocal billing agreement. These services would fall under modifier Q5 (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).

In these situations, the doctor who "owns" the patients, not necessarily the one who saw them at those visits, bills out the provided services under his NPI and appends modifier Q5 to indicate he really did not see the patient. The physicians don't exchange any money because the services will even out over time.

Here are a few takeaways on the matter of locum tenens and reciprocal billing:

• There is no wiggle room on the 60-continuous days for either LT or reciprocal billing arrangements.
• LTs cannot be hired to cover for deceased regular physicians because when the provider passes away, his NPI and Provider Transaction Access Number (PTAN) are deactivated. LTs can only be used for living physicians.
• An LT cannot be utilized for high volumes, overbooking, or practice expansions.
• Reciprocal billing allows for doctors to switch-hit, covering each other's time off - it is a mutual exchange and benefits both parties.
• To use modifiers Q5 and Q6, the physician must be unavailable to provide services. This means that the provider should be out of the office while the substitute physician provides services.
• Don't confuse the modifiers - Q5 for reciprocal billing and Q6 for LT - or your claims will be denied.