Reciprocal billing/Locum Tenens: Q5 or Q6? What a coder needs to know.

The term “locum tenens” is Latin for “to hold the place of”. In the medical profession, this means a provider who essentially ‘fills in’ for a provider who is temporarily absent from their practice.

In the medical profession, it is not uncommon for physicians to hire a substitute or ‘locum’ to take over their practice when they are absent for an extended period of time. These substitute physicians usually do not have a practice of their own, and move from job to job as a ‘permanent’ temporary employee.

A coder needs to understand the rules of locum tenens billing and reciprocal billing arrangements. This understanding is crucial to keeping the revenue flow in the practice smooth, and not interrupted by unpaid or denied claims by CMS or your private insurance payers. Medicare has put forth some guidelines regarding billing of claims in these circumstances. The HCPCS modifiers Q5 and Q6 are designated for locum tenens usage and reciprocal billing arrangements.

HCPCS Modifier Q6 - Payment Under Locum Tenens Arrangement

The usage of modifier Q6 was developed by CMS specifically to address billing concerns when a physician is away from their regular practice. (i.e. for vacation, illness, education, etc).

To help solve this issue, the Q6 modifier designation informs Medicare, that a ‘locum’ has stepped into the practice, on a temporary basis, to provide continuation of medical care.

The locum tenans guidelines only apply to providers such as MD’s and DO’s. Locum tenens does not apply to providers such as Physical Therapists, or Nurse Anesthetists. If a coder is unsure to bill locum tenans for a Nurse practitioner (NP) , Physician Assistant (PA) , or Certified Nurse Midwife (CNM), they should check with their local Medicare carrier for clarification of the modifier Q6 and if it is appropriate for these provider types. At this time, the CMS guidelines only state locum billing in relation to MD’s and DO’s.

CMS allows a locum to provide services for a maxium of 60 continuous days for the absentee physician. CMS does not specifically state how long a ‘break’ there needs to be in between the continuous 60 day time limit. If you know that your physician is going to be out for more than 60 days, an alternative plan for physician coverage and patient care would need to be made.

HCPCS Modifier Q5 - Service Provided by a Substitute Physician Under a Reciprocal Billing Arrangement

The usage of modifier Q5 is to be used only for a reciprocal billing arrangement, and noted on the CMS 1500 claim form. The reciprocity billing arrangement comes into play, when one physician covers for another, then provides care for those patients, who are normally cared for by physicians within the same practice or group practice. i.e. Physician “A” is providing coverage for Physician “B”, while Physician “B” is out of the office.

In the scenario above, the covering physician must be a permanent part of the existing office practice, and is not hired from the outside, or operating under a different tax ID number, or billing for services provided under a ‘group practice’ tax ID number.. Again, CMS limits this to 60 continuous calendar days where a reciprocal billing agreement is in effect.

Basic rules of billing for a locum tenes or reciprocal billing physician:

1. Use the Q5 or Q6 modifier in box 24d of the CMS-1500 form for each line item in the claim. (append the modifier for each line item service)
   
   
2. Enter the regular physician's NPI in box 24k of the CMS-1500 form.
   
   
3. Add the NPI and name of the “locum” or “reciprocal” physician in the ‘notes” line of the CMS 1500 form (not mandatory, but helpful)
   
   
4. Keep track of the locum's NPI and his/her services in your files in case your carrier requests them.
   
   
5. Keep track of the calendar dates the locum was providing these services in case your carrier requests this information.

Coders need to keep in mind that ‘locum tenens’ billing was created for usage by CMS, for physicians that are providing services under the Medicare payment system. Private insurance payers may not recognize services provided by a locum or reciprocal billing agreements. It is wise to contact those insurance payers ahead of time (if possible) to determine what course of action you should take for submitting your claims while your physician is absent from the practice.