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Jurisdiction 11 Part B
Locum Tenens and Reciprocal Billing

The Social Security Amendments Act of 1994 allowed, on a permanent basis, for payment to be made to a patient’s regular physician and not a substitute physician, in the event that a locum tenens or reciprocal billing arrangement existed. The regular physician must submit the services using his/her own National Provider Identifier (NPI).
 
Locum Tenens Arrangements
Physicians may retain substitute physicians to take over their professional practices when they are absent for reasons such as illness, pregnancy, vacation or continuing medical education.

  • These substitute physicians, known as 'locum tenens' physicians, generally have no practice of their own and move from area to area as needed
  • The regular physician generally pays the substitute physician a fixed per diem amount. The substitute physician’s status is that of independent contractor, rather than employee, and his/her services are not restricted just to the physician’s office.
  • Services of non-physician practitioners (e.g., CRNAs, NPs and PAs) may not be billed under the Locum Tenens or Reciprocal Billing reassignment exceptions. These provisions apply only to physicians.

The regular physician may submit a claim under the locum tenens arrangement using his/her own NPI and, if assignment is taken, receive payment for covered visit services if the following conditions are met:

  • The regular physician is unavailable to provide the visit/services
  • The Medicare patient has arranged or seeks to receive the visit/services from the regular physician
  • The regular physician pays the locum tenens physician for his/her services on a per diem or similar fee-for-time basis
  • The substitute physician does not provide the visit/services to Medicare patients over a continuous period of longer than 60 days
  • The regular physician identifies the services as substitute physician services with HCPCS modifier Q6 (services furnished by a locum tenens physician). Until further notice, the regular physician must keep on file a record of each service along with the substitute physician’s NPI.

Exception to the 60-day limitation for locum tenens billing:

  • Section 116 of the Medicare, Medicaid and SCHIP Extension Act of 2007 extended the exception to the 60-day limit on substitute physician billing for physicians being called to active duty in the Armed Forces for services furnished from January 1, 2008, through June 30, 2008. Section 116 of Public Law 110-173 extended the accommodation of physicians ordered to active duty in the Armed Forces, enacted by Public Law 110-54, by striking 'January 1, 2008,' and inserting 'July 1, 2008'.
  • Essentially, both legislative acts allow a physician being called to active duty to bill for the services furnished by a substitute physician for longer than the 60-day limitation

If postoperative services are furnished by the substitute physician, the services cannot be billed with HCPCS modifier Q6 since the regular physician is paid a global fee.

  • If services are provided by a substitute physician over a continuous period of longer than 60 days, the regular physician must bill the first 60 days with HCPCS modifier Q6
  • The substitute physician must bill for the remainder of the services in his/her own name
  • The regular physician may not bill and receive direct payment for services over the 60-day period
  • A new period of covered visits can begin after the regular physician has returned to work

For a medical group billing under the locum tenens arrangement, it is assumed that the locum tenens physician is paid by the regular physician.

  • The term 'regular physician' includes a physician who has left the group and for whom the group has hired the locum tenens physician as a replacement
  • A physician who has left a group, and for whom the group has engaged a locum tenens physician as a temporary replacement, may still be considered a member of the group until a permanent replacement is obtained

Reciprocal Billing Arrangements
On an occasional reciprocal basis, a patient’s regular physician will arrange for a substitute physician to provide visit/services, including emergency visits or related services. Under a reciprocal billing arrangement, the patient’s regular physician may submit a claim to Medicare Part B using his/her own NPI and, if assignment is accepted, receive payment if the following conditions are met:

  • The regular physician is unavailable to provide the visit/services
  • The Medicare patient has arranged or seeks to receive the visit/services from the regular physician
  • The substitute physician does not provide the visit/services to Medicare patients over a continuous period of longer than 60 days
  • The regular physician identifies the services as substitute physician services by using HCPCS modifier Q5 (services furnished by a substitute physician under a reciprocal billing arrangement)
  • Until further notice, the regular physician must keep on file a record of each service provided by the substitute physician along with the substitute physician’s NPI

If postoperative services are furnished by the substitute physician, the services cannot be billed with HCPCS modifier Q5 since the regular physician is paid a global fee.

  • If services are provided by a substitute physician over a continuous period of longer than 60 days, the regular physician must bill the first 60 days with HCPCS modifier Q5 (services furnished by a substitute physician under a reciprocal billing arrangement)
  • The substitute physician must bill the remainder of the services in his/her own name
  • The regular physician may not bill and receive payment for services over the 60-day period
  • A new period of covered visit/services can begin after the regular physician has returned to work

References:


 

last updated on 07/01/2014
ver 1.0.51