The Lowdown on Locum Tenens – Know when and How to Bill for a Substitute Physician

The Lowdown on Locum Tenens – Know when and How to Bill for a Substitute Physician

By John R. Outlaw, CHC, CHBME| HBMA Billing
In its Compliance Program Guidance for Third Party Medical Billing Companies, the Office of Inspector General (OIG) identified a specific list of particular risk areas that billing companies should address. The OIG went on to characterize them as a “compilation of several years of OIG audits, investigations, and evaluations and should provide a solid starting point for a company’s initial effort.” Included among this list of risk areas is the “knowing misuse of provider identification numbers which results in improper billing.” Two ways that this comes into play are with the use of substitute physicians to fill in for a sick or vacationing physician or as short time coverage after a regular physician leaves the practice. Billing companies will do well to ensure that staff and physicians alike understand the rules that govern the use and proper billing for the services of these locum tenens physicians.
We need to understand two important concepts involved with the use of locum tenens physicians. First, the Latin term locum tenens actually means “lieutenant,” not in the context of a military rank as we often think of it, but in a much broader sense as someone who works “in lieu of” someone else when that person is not personally available (e.g., “The CEO had one of his lieutenants attend the luncheon for him.”). The second is that the very nature of the job is understood to be temporary, and under the locum tenens rules, Medicare places a maximum of 60 days that one physician may be contracted to fill in for another physician. A locum tenens provider must always be filling in for another provider who is not able to perform his or her duties on a particular day due to absence from the office (e.g., out sick, on vacation, away on business, etc.). Additionally, under this rule, a locum tenens provider may only bill for his or her services for up to 60 days. By the 61st day, the substitute physician must be enrolled as a member of the group and begin billing for the work that he or she performs under his or her own NPI.
The Medicare rules regarding billing for the services of a locum tenens physician are located in the Medicare Claims Processing Manual at Chapter 1, Section 30.2.11. In order to bill for the services of a substitute physician under Medicare’s locum tenens rule without enrolling that physician as a member of the group, all of the following criteria must be met:

  1. The regular physician must be unavailable to provide the services (i.e., sick, vacation, business travel, etc.).
  2. Compensation for a locum tenens physician must be on a per diem or similar fee‐for‐time basis.
  3. The regular physician or group (as the case may be) cannot bill for the services of a locum tenens physician for a continuous period of longer than 60 days.
  4. All claims submitted for services provided by the locum tenens physician while the regular physician is unavailable must include the “Q6” modifier to indicate that a substitute physician provided the services.

Note that the 60 days is a “consecutive” 60‐day period. Therefore, a locum tenens physician providing coverage three days a week beginning on September 1 can still only provide services for the same absentee physician through October 31. This also applies even if several different locum tenens physicians provide coverage during the 60‐day period! This is a very important point and the source of much of the confusion around the proper use of billing for these services because the limitation is tied to the billing of the Q6 modifier, not to the number of days that any particular locum tenens physician provides coverage. Therefore, a new 60‐day period for billing the services of a locum tenens physician does not commence because of a break in service of the substitute or locum tenens physician. Starting a new 60‐day period requires a break in the absence of the physician for whom a substitute physician is necessary. After the regular physician returns to work and provides services for at least one day, then a locum tenens physician can again provide services as a substitute for that regular physician for up to 60 consecutive days.
Medicare also permits a group practice to bill for services of a substitute physician who fills in after a physician has left the group practice by using applying the locum tenens policy while the new physician is being enrolled/credentialed by Medicare. That is, the group may bill for services of a substitute physician under the regular physician’s NPI, even after the regular physician has left the group. However, regardless of circumstances, at the end of 60 consecutive days, the substitute or locum tenens physician may no longer bill under the regular physician’s NPI with a Q6 modifier. Beginning on the 61st day, the substitute or locum tenens physician must submit claims under his or her own NPI.
Finally, it is important to note that a locum tenens physician can only provide services in connection with the absence of a regular physician. These rules do not support the use of a contracted physician to provide part‐time or “temp” services for any reason unrelated to the absence of a regular physician for whom the contracted physician is substituting. A physician who is contracted on a part‐time basis for any purpose other than to fill in when the regular physician is out of the office and not performing services for a period of time must be enrolled as a member of the group and his or her services must be billed under his or her own NPI.