Tenets for locums | aad.org
Tenets for locums

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, Calif., represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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Finally, after several years in private practice, you courageously decide to reward yourself for your hard work and distance yourself from your office for a three-week vacation. As such a prolonged absence would also separate your patients from your practice for an equal amount of time, you decide to hire an independent dermatologist to attend to your patients in your absence. Now what? Does the substitute physician just have to show up and all is well, or are there statutory requirements that have to be met?

Medicare recognizes two types of substitute physician arrangements under which billing for services delivered in your office may be executed under your name and NPI. The first is locum tenens and the second is a reciprocal billing arrangement. Both are subject to very similar requirements, as listed below.

Locum tenens

  • The regular treating and billing physician is absent from his/her office or medical group.
  • A patient is treated in the regular physician’s office by a substitute physician.
  • The locum tenens physician is an independent contractor, and not an employee.
  • The locum tenens physician has no practice of his/her own.
  • The locum tenens physician is paid for services on a per diem basis or similar arrangement. [pagebreak]

Reciprocal billing arrangement

  • The absent physician has an arrangement with another physician to replace him/her on an occasional basis.
  • The substitute has his/her own practice.
  • The reciprocal billing arrangement may be made with more than one physician.

Locum tenens and reciprocal billing requirements

  • Your office or group bills for substitute services under your name and NPI along with a modifier to be entered in item 24d of the CMS-1500 claim form:
    • Q6 modifier for a locum tenens physician.
    • Q5 modifier for a reciprocal billing physician.
  • You keep a readily accessible record of each service done and billed during your absence along with the substitute physician’s NPI.
  • Your substitute must be a physician to qualify for locum tenens or reciprocal billing (not a physician assistant or nurse practitioner).
  • If billing Medicare, the substitute physician must have a Medicare Provider Number (enrolled in Medicare as a provider).
  • The substitute physician provides services for a continuous period of no more than 60 days.
  • After 60 continuous days of providing covered services the substitute physician must start billing under his/her own name and NPI, rather than the absentee physician’s.
  • The 60-continuous-day period starts with the first day that a substitute physician bills for services, and not from the first day that a physician is absent from his/her office.
  • If a physician is called to active duty in the Armed Forces, then the 60-day limit does not apply.
  • Once the absent physician returns and begins billing for services, any subsequent absence requiring a substitute will trigger a new maximum 60-day period. [pagebreak]

Detailed Medicare regulations concerning substitute physicians may be found in the IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 30.2.1 and 30.2.11, available at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf.

Note that private insurers may not necessarily follow Medicare guidelines. It is prudent to know the private insurers’ substitute physician billing requirements prior to submitting bills.

Ordinarily, your malpractice insurance will cover the substitute physician in your absence. Coverage may be automatic, requiring no prior notification of your insurer, or your insurer may require that you contact it in advance of your absence in order to credential a locum tenens physician prior to approving insurance. Clearly, it is imperative that you discover your insurer’s locum tenens requirements prior to your absence. Your insurer’s website is likely to provide information on locum tenens coverage and/or list a contact telephone number for information. 

Example 1: Prior to your absence you excised an atypical nevus from a patient’s back. Five days later, once you are gone, the patient returns to your office concerned about redness and puffiness along the excision line. Your substitute physician examines the operative site, determines that there is a minor reaction to suture traction, and reassures the patient, giving additional care instructions. Your office bills a 99212 E/M code for the visit. [pagebreak]

Answer: Incorrect. Although a physician different from you evaluated the patient, that physician was your substitute in your office. Your office may not bill for a separate charge, since you, the patient’s regular physician, were paid under a global surgical package rule, whereby there is a 10-day postoperative period during which services related to the surgery are included in the procedure valuation and are not separately payable. If the patient had gone to another, unrelated office for an evaluation then those services would have been payable, as they would have been provided by a non-locum tenens physician, and the billing would not have been done under your name and NPI identifier.

Example 2: You are called to active duty in the Armed Forces and are absent from your office for 92 continuous days. As you are serving your country, your office may continue billing for a locum tenens physician under your name and NPI during the last 32 days of your absence.

Answer: Correct. Public Law 110-54 created an exception to the 60-day limit for physicians called to active duty in the Armed Forces. Your office may continue billing under your name and NPI for the duration of your continuous absence.

Example 3: You have added a recent graduate from dermatology residency to your practice. While the new dermatologist’s Medicare enrollment is being processed you want to be paid for his/her services. So, you bill Medicare for the new physician’s services under your identifier as a locum tenens, with the Q6 modifier.

Answer: Incorrect. Locum tenens specifies a temporary replacement by an outside physician. In this case the new physician is neither a replacement nor an outside physician. It is inappropriate to bill for the new physician’s services under the locum tenens provision.