Practice managers, healthcare providers, and clinic owners prioritize continuous patient care and revenue flow when a regular physician is absent. Consequently, the solution often involves locum tenens physicians—temporary substitutes who keep your practice running smoothly. However, Locum Tenens Billing Rules represent a specialized area, and strict Medicare rules govern this area. Understanding these nuances is crucial for preventing frustrating claim denials. Therefore, mastering these billing rules is paramount for maintaining your financial health.
The Core of Locum Tenens Billing: The 60-Day Rule and Q6 Modifier
Locum tenens billing allows a facility to bill for services provided by a substitute physician. Specifically, you bill as if the absent regular physician provided them. Crucially, services are billed under the absent physician’s name and National Provider Identifier (NPI). The locum tenens provider cannot bill under their own NPI for these services during this period.
The Strict 60-Day Rule
Centers for Medicare & Medicaid Services (CMS) guidelines generally limit the entire arrangement to 60 continuous calendar days per absent physician. Staff often refer to this period as a “fee-for-time compensation” arrangement. Exceptions exist for situations like military call-ups, which allow extended coverage.
The Indispensable Q6 Modifier
To signify that a temporary substitute furnished the services, you must append the Q6 modifier to the CPT/HCPCS codes on the claim. Furthermore, you bill claims at 100% of the physician fee schedule under the absent physician’s NPI. The Q6 modifier is necessary in outpatient settings; it prevents the payer from denying the claim as a duplicate.
State Medicaid Note: Be mindful that state Medicaid programs may have additional requirements. For instance, in Georgia Medicaid, the locum provider must already be enrolled and active in the state’s Medicaid program. This enrollment is required for the payer to use the Q6 modifier and process the claim successfully. Always check your specific state Medicaid rules.
Strategizing for Extended Coverage: When 60 Days Aren’t Enough
What happens if your need for temporary coverage is expected to extend beyond the 60-day limit? Your practice must utilize two primary strategies to maintain compliant billing and avoid financial disruption.
1. Enroll the Locum in Payer Networks (The Permanent Solution)
The most sustainable solution is to enroll the locum physician in payer networks—Medicare, Medicaid, and commercial payers—as soon as possible. After the 60-day Medicare window expires, you must switch to billing under the locum’s own NPI. You treat them like permanent staff at this point. Starting this enrollment early is essential, since the credentialing process can be notoriously time-consuming, often exceeding 90 to 120 days.
2. Reset the 60-Day Clock (The Tactical Solution)
A less permanent, but effective, tactical move involves resetting the 60-day count. This requires the absent regular physician to return to the practice, even briefly, to provide services. Once they return, you may re-engage the same (or a different) locum under a fresh 60-day period. Staff can repeat this cycle as needed to bridge extended absences, ensuring continuous Locum Tenens Billing Rules compliance.
Scenario Spotlight: Proper Billing in Action
Imagine Dr. A is going on a 70-day medical leave. Your practice hires Dr. L (the locum) to cover.
- Days 1–60: You bill under Dr. A’s NPI, using the Q6 modifier on all outpatient CPT codes.
- Day 61: The 60-day limit is reached. You must switch to billing under Dr. L’s own NPI (assuming staff successfully enrolled Dr. L in all necessary payer networks).
- If Dr. L wasn’t enrolled: Dr. A would need to return, even briefly (e.g., for one day). After this return, a new 60-day period could begin, and you’d revert to billing under Dr. A’s NPI with the Q6 modifier.
4 Key Takeaways for Practice Compliance
Proper recordkeeping and modifier usage are non-negotiable for smooth locum tenens billing. Failing to comply with these Locum Tenens Billing Rules results in immediate, costly denials.
- NPI Usage: Claims must always carry the NPI of the regular, absent physician (e.g., CMS-1500 block 24J) during the initial 60-day period, not the substitute’s NPI.
- Modifier: The Q6 modifier is required in outpatient settings; it indicates the use of a substitute physician.
- Documentation: Maintain a robust record of every service the substitute provided. This record must include the substitute’s NPI and the exact dates of the coverage arrangement. Payers like A/B MACs must have these records readily available for audit.
- Payer-Specific Rules: Always check each Medicaid and commercial payer’s rules, since they may not fully align with Medicare’s standards regarding duration or modifier use.
Locum tenens arrangements are a lifeline for practices, ensuring patient access and stable revenue. However, correct use of these billing rules is paramount to avoid critical claim denials.
Need Expert Help with Locum Tenens Billing?
Dealing with the complexities of NPIs, the Q6 modifier, and the 60-day clock can quickly become a burden for busy practices. If you’re looking for a partner to ensure your claims are compliant and your revenue cycle is optimized, reach out to us. We offer comprehensive revenue cycle management solutions designed to take the guesswork out of Locum Tenens Billing Rules and maximize your practice’s reimbursement.
Get in touch with us today to streamline your billing and focus on what you do best: patient care.
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