How Billing for Locum Tenens Works

When your doctors decide to take a vacation, Medicare allows you to bring in a temporary replacement, if necessary, to keep a practice running. You can bill the services of the replacement, known as a locum tenens physician, using the physician identification number of the doctor who is away.

The Basics

When billing for locum tenens providers, 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.

Locum Tenens Engagements Less Than 60 Days

Locum stay is limited to 60 consecutive days. Medicare rules state the locum tenens physician may work in your practice as a locum for only 60 consecutive days. If the locum is subbing for a doctor who will return to the practice, you can use the same locum tenens physician if your doctor returns, then leaves again.

The Center for Medicare and Medicaid Services (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.

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.
  • Modifier Q6 (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.
    Note: 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.

Locum Tenens Engagement Past 60 Days

There are times when a locum tenens provider is needed to stay beyond the prescribed Medicare 60-day limit. Should this happen, an organization can choose from one of the following options:

  1. 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.
  2. 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.)

Additional Tips

  • Claims must contain the NPI of the regular physician and not the locum or substitute physician. Entered in CMS-1500 claim in block 24J.
  • CPT/HCPCS codes must have modifier Q6 appended as this indicates the billed services were furnished by the locum or substitute physician. Added in box 24D.
  • Record each service 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. 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.