How does locum tenens billing work?
Any time a physician is absent, a patient isn’t being seen, and revenue isn’t being produced. Most hospitals and practices use locum tenens physicians to ensure patients have access to top-quality care and revenue isn’t being lost due to a vacancy. At LocumTenens.com, we are often asked about working with payers to bill for services provided by locum tenens physicians. There are a few rules of which to be aware, and we’ve attempted to simplify them for you here.
The Basics: Locum Tenens Billing
The first thing to remember when billing for locum tenens providers is that the rule published governing your capacity for reimbursement of their services is a Medicare Rule and is only applicable to Medicare and for physician services. For billing inquiries relating to Medicaid or commercial payers, you’ll need to validate with the individual payers if they have adopted the Medicare rule, and if not, understand the specific rules that govern their reimbursement of locum tenens providers.
The Center for Medicare and Medicaid Services (CMS) has stated that a locum tenens physician can provide services to Medicare patients over a continuous period of no longer than 60 days. The only exception given was if the regular physician was called for active duty in the Armed Forces. For simplicity's sake, we have outlined locum tenens billing procedures in two categories: those locum tenens engagements that are expected to last less than 60 days and those that are expected to extend past 60 days.
Planned Duration of Locum Tenens Need < 60 Days
As general requirements for locum tenens provider use, CMS has provided guidelines that will enable the regular physician or physical therapist to receive the Part B payment for covered visit services of a substitute physician or physical therapist.
This is allowed if:
- The regular physician or physical therapist is unavailable to provide the service.
- The Medicare beneficiary has arranged or seeks to receive the services from the regular physician or physical therapist.
- The regular physician or physical therapist pays the substitute for his/her services on a per diem or similar fee-for-time basis.
- The substitute physician or physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days. The only exception is when the regular physician is called for active duty in the Armed forces.
- NOTE: The 60-day count would start on the first day the locum tenens physician sees a patient and not when the regular physician took their absence.
- Q6 Modifier (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) is appended after the CPT code.
- If the only services a physician performs in connection with an operation are postoperative services furnished during the period covered by the global fee, these services need not be identified on the claim as services furnished by a substitute physician.
- GA Medicaid has implemented a new regulation regarding the use of the Q6 modifier. In order to use the Q6 on a locums provider in the state of Georgia, they must already be actively enrolled in GA Medicaid in some fashion. The active enrollment does not need to be with the facility tied to the locums assignment, it can be any facility. If the provider is not already active in the program, the claims will be denied.
Planned Duration of Locum Tenens Need > 60 Days
We recognize there are often occasions where the need for a locum tenens provider is expected to extend beyond the prescribed Medicare time limit of 60 days. Should this situation arise, organizations can choose one of two routes in order to continue billing for locum tenens physician services rendered past the 60-day limit:
- Upon acquisition of a locum tenens provider, begin enrolling him/her in the organization’s contracted payer mix (Medicare, Medicaid, commercial payers, etc.) prior to their start date or as soon as possible upon starting. At the end of the Medicare 60-day window, you would then bill under the locum tenens physician NPI number as if they were a permanent physician.
- The absent provider may return to the practice for a brief period of time, which would reset the 60-day window and allow you to reuse the same locum tenens physician or contract for a new locum tenens physician for an additional 60-day engagement. (This process can be repeated for as long as necessary.)
Clerical Reminders and Final Thoughts
- Claims must contain the NPI of the regular physician and not the locum or substitute physician. This is entered in CMS-1500 claim in block 24J.
- CPT/HCPCS codes must have the modifier Q6 appended as this would indicate that the billed services were furnished by the locum or substitute physician. This is added in box 24D.
- A record of each service provided by the substitute physician or physical therapist must be kept on file along with the substitute physician’s or physical therapist’s NPI. This record must be made available to the A/B MACs Part B upon request.
- The use of a locum tenens physician should allow your facility or practice to continue providing outstanding care to your community without sacrificing revenue rightly due. Organizations need not fear billing for locum tenens physician services. If you anticipate the need for locum tenens services will extend past 60 days, we highly recommend beginning the payer enrollment process for your locum tenens provider prior to their arrival at your facility/practice.