Part B Insider (Multispecialty) Coding Alert

Published on Sat Sep 19, 2009 PDF

Medicare doesn't consider locum tenens an appropriate billing scenario for an uncredentialed physician.

Myth: Tired of waiting for your new physician's Medicare credentialing to process? You can just report the new doctor's service under an existing physician's ID number and append the locum tenens modifier to it, right?

Reality: No way. Locum tenens is designed to represent services performed "in the absence of the regular physician," according to chapter 1 of the Medicare Claims Processing Manual.

The scenario: Many practices have grown frustrated at wait times for Medicare credentialing when they hire a new physician, so they simply report the new physician's service as if it was performed by a locum tenens doctor, but that goes against the original intent of the locum tenens rules, says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

"Some practices are billing this way and they may even say they heard the advice at a conference," Buechner says. "But you have to go back to the original source -- chapter 1 of the Medicare Claims Processing Manual -- which indicates that locum tenens applies to cases where the regular physician is absent due to illness, pregnancy, vacation, or continuing medical education."

Plus: "One of the stipulations of locum tenens is that you pay the doctor taking over for you on a per-diem basis," says Crystal S. Reeves, CPC, CPC-H, consultant with The Coker Group in Alpharetta, Ga. "So if you're just billing a new physician as a locum tenens, not only are you billing incorrectly but you've made a mistake in your payment structure as well."

Billing for a locum tenens' services is fairly straightforward, experts say. You have to append modifier Q6 (Service furnished by a locum tenens physician) to all of the temporary doctor's claims and bill under the NPI of the physician the locum is replacing. Also, you should include the NPI of the temporary doctor in box 23 on the CMS-1500 billing form.

You can bill for a locum tenens for 60 continuous days, Buechner says. In rare cases when a physician is on active duty in the Armed Forces, Medicare may allow you to bill locum tenens services beyond the 60-day limit, but in most other cases, MACs are very strict with the timing.

"In one case I recall, a doctor had cancer and they brought in a locum physician for 60 days," Reeves says. "When the 60 days were up, that doctor couldn't come back, so the practice asked the carrier for an extension and the carrier would not extend it past the 60 day limit."

In some cases, practices will bill the new physician's services under an existing doctor's NPI and just leave off the Q6 modifier, acting as if the other doctor personally performed the service.

"Some people try to slide under the radar this way, but eventually the wires will cross with your Medicare carrier and the discrepancy will be discovered," Buechner says. "It's smarter to just do it by the book."

In fact, the OIG addressed this issue by offering the following example of "misrepresentation of services to the Federal health care programs in the Oct. 5, 2000 Federal Register:

"When the practice bills for a service performed by Dr. B, who has not yet been issued a Medicare provider number, using Dr. A's Medicare provider number. Physician practices need to bill using the correct Medicare provider number, even if that means delaying billing until the physician receives his/her provider number."

"Locum tenens is a particularly vulnerable kind of activity because the only way you really capture it is if people are actually using the modifiers or they are audited," Buechner says.

To read the Medicare Carrier's Manual's section on locum tenens bill-ing, visit http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.