Physician Payment Under Locum Tenens Arrangements – Claims Submitted to Carriers

A. Background

It is a longstanding and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the substitute physician’s services as though he/she performed them. The substitute physician generally has no practice of his/her own and moves from area to area as needed. The regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than of an employee. These substitute physicians are generally called “locum tenens” physicians.

Section 125(b) of the Social Security Act Amendments of 1994 makes this procedure available on a permanent basis. Thus, beginning January 1, 1995, a regular physician may bill for the services of a locum tenens physicians. A regular physician is the physician that is normally scheduled to see a patient. Thus, a regular physician may include physician specialists (such as a cardiologist, oncologist, urologist, etc.).

B. Payment Procedure

A patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices, if:

• The regular physician is unavailable to provide the visit services;

• The Medicare beneficiary has arranged or seeks to receive the visit services from the regular physician;

• The regular physician pays the locum tenens 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 subject to the exception noted below; and

• The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished by a locum tenens physician) after the procedure code. When Form CMS-1500 is next revised, provision will be made to identify the substitute physician by entering his/her unique physician identification number (UPIN) or NPI when required to the carrier upon request.

EXCEPTION: In accordance with section 116 of the “Medicare, Medicaid, and SCHIP Extension Act of 2007” (MMSE), enacted on December 29, 2007, the exception to the 60-day limit on substitute physician billing for physicians called to active duty in the Armed Forces has been extended for services furnished from January 1, 2008 through June 30, 2008. Thus, under this law, a physician called to active duty may bill for substitute physician services from January 1, 2008 through June 30, 2008 for longer than the 60-day limit.

If the only substitution services a physician performs in connection with an operation are post-operative services furnished during the period  covered by the global fee, these services need not be identified on the claim as substitution services.

The requirements for the submission of claims under reciprocal billing arrangements are the same for assigned and unassigned claims.

C. Medical Group Claims Under Locum Tenens Arrangements

For a medical group to submit assigned and unassigned claims for the services a locum tenens physician provides for patients of the regular physician who is a member of the group, the requirements of subsection B must be met. For purposes of these requirements, per diem or similar fee-for-time compensation which the group pays the locum tenens physician is considered paid by the regular physician. Also, a physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may bill for the temporary physician for up to 60 days. The group must enter in item 24d of Form CMS-1500 the HCPCS modifier Q6 after the procedure code. Until further notice, the group must keep on file a record of each service

provided by the substitute physician, associated with the substitute physician’s UPIN or NPI when required, and make this record available to the carrier upon request. In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her provider identification number (PIN) or NPI when required on block 24J of the appropriate line item.

Physicians who are members of a group but who bill in their own names are generally treated as independent physicians for purposes of applying the requirements of subsection A for payment for locum tenens physician services. Compensation paid by the group to the locum tenens physician is considered paid by the regular physician for purposes of those requirements. 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.

The physician who is going to be absent for a short period and will not actually perform the service is the regular, but absent, physician. A locum tenens billing arrangement is intended to promote the continuation of the billing process for regular, but absent, physicians and their cooperation in helping the locum tenens to complete of this form may be necessary. Information regarding the regular, but absent, physician appears on the right-side box, and is completed by the applicant by supplying:

* The regular, but absent, physician’s full name and their individual Medicaid Provider Number. Show the group number also, if any billings for the substitute will utilize a group number;

* The signature of the absent Physician;

* The phone number of the physician/billing office that can answer most routine questions;

* As post office boxes are transitory, they may not be used. Please indicate a permanent address for the regular physician, a physical address where the services will be performed is also allowable; and

* The specific dates the services. They may not to exceed sixty (60) consecutive days. Terms like ongoing or current will not be accepted. If the services are anticipated to exceed sixty (60) days, then a regular provider number application must be made concurrent with the locum tenens. A regular provider application may be secured by calling Medicaid’s fiscal agent toll-free at 877-838-5085. Billing under locum tenens for periods in excess of sixty (60) consecutive days are specifically not authorized by the Kentucky Medicaid Program


The holder of the valid provider number is required to bill the services of any locum tenens physician by utilizing the Health Care Procedure Coding System (HCPCS) with the procedure modifier code “Q-6” in item 24d of Form HCFA-1500, for every procedure performed by the locum tenens physician. Failure to bill correctly may be considered a violation of the terms of the Provider Agreement.

Note: for this process the “regular, but absent” physician hires the “locum tenens” physician. The temporary physician who is going to stand-in and actually perform the services for a short duration for the absent physician is the locum tenens physician. The locum tenens physician or his/her agent may fill out the form. An ORIGINAL SIGNATURE of the locum tenens physician is required, a signature stamp may not be used, nor can others sign for this physician. Failure to complete and have a valid original signature on the form in its entirety may result in Medicaid claims not processing timely and completely. All required documents that are to be attached are for the locum tenens physician. A locum tenens physician shall be otherwise be required to be in good standing with all applicable regulatory boards and maintain malpractice insurance to ensure the protection of the Medicaid recipients they treat pursuant to 42 USC §1396a(a)(19).

The locum tenens physician on the left-side box shall enter:

* The locum tenens physician’s full name;
* The phone number of the locum tenens doctor where they can be reached during normal office hours if clarification or additional information is needed; (please include area code and extensions)
* As post office boxes are transitory, they may not be used. Please indicate a permanent address for the locum tenens physician;
* The SSN for the locum tenens physician;
* Indicate if the placement is based upon an outside contract agency; if YES, provide the full name and mailing address of the contract agency. A sheet may be attached to complete this process.
* Credentialing Agent contact information, if applicable.

– AND –

* A copy of a valid current physician license for the locum tenens is attached; and
* Proof of the malpractice insurance coverage maintained for the locum tenens physician for the anticipated period of the services are to be performed is also attached; and
* Signature of the Locum Tenens

Claims & Documentation

A record must be kept of each service provided by the locum physician along with the locum’s physician identification number. A seasoned locum tenens provider will be accustomed to the required documentation.

Medicare requires claims for services provided by a locum tenens physician to include the Q6 modifier, which designates services were performed by a locum tenens physician, in box 24D of the CMS-1500 form.

Scenario Two: Billing for locum tenens coverage for a vacancy Medicare permits billing under the Q6 modifier on behalf of a physician who has left a practice for a period of no more than 60 days. The same rules apply as above. Scenario Three: Billing for locums coverage for new growth or seasonal coverage In the event that you must hire locum tenens physicians to cover seasonal and/or peak demand or while filling a vacancy created because you are growing your practice, all payers will require the locum physician to go through the normal credentialing and enrollment processes. Some locum tenens agencies, like, will assist with credentialing. You will need to complete all forms and submit them at least 60 days prior to the first working day of the locum physician to make sure the payers will reimburse the group or employer for their services.

Billing for the services of locum tenens physicians can be a little tricky and timing is important, but it is well worth the investment of time when your reimbursements flow in as usual. Generally, the professional fees collected for services provided by a locum tenens physician more than cover their per diem rates and travel costs. Hiring locum tenens provides the double bonus of allowing you to maintain revenue and prevent patient attrition.