Anesthesia Coding Alert

A locum tenens physician may be a temporary addition to your practice, but if you don't keep proper documentation, the headaches may last long after he leaves.

Billing for a locum tenens' services is fairly straightforward, experts say. You have to append modifier Q6 (Service furnished by a locum tenens physician) to all of the temporary doctor's claims and bill under the NPI of the physician the locum is replacing. Also, you should include the temporary doctor's NPI in box 23 on the CMS-1500 billing form.

Timing is everything: You can bill for a locum tenens physician for 60 continuous days. If the locum leaves your practice for a time and then comes back, the 60-day clock starts again. If a physician permanently leaves your practice, you can replace her with a locum tenens, as long as the doctor who left bills using a different tax ID at her new practice.

The tricky part: Medicare requires you to maintain a separate record of all the claims you submitted for the locum tenens physician. There are a few ways to do this, experts say.

You can make an extra copy of each of the locum's claims and keep the copies in a separate paper file for the locum tenens, or you can use your computer system to track the locum tenens. The computer system at Einstein Healthcare Network in Philadelphia allows billing staff to look up the NPI listed in box 23 of the billing form, says coding specialist Christine Endes. "This way, we can reference it at any time," she adds.

New numbers: Endes and her colleagues also assigned different numbers internally to locum tenens physicians, for tracking purposes. Normally, if staffers type in a physician's NPI, the computer will print out a bill under that doctor's name, but typing in a special number for the locum tenens produces a bill with the absent doctor's name and modifier Q6 attached -- and it adds the locum's NPI to box 23.

When you report locum tenens services, don't confuse modifier Q6 with reciprocal billing (modifier Q5, Service furnished by a substitute physician under a reciprocal billing arrangement). You use modifier Q5, for example, when your physician arranges with another doctor to cover each other's patients on weekends. In this situation, Doctor A will see Doctor B's patients and bill under Doctor B's NPI using modifier Q5. The physicians don't exchange any money because the services even out over time.

Stick With True Locums Situations

Many coders agree that people only have trouble with locum tenens when they try to use locum tenens billing for a couple of situations it wasn't designed for:

1. a newly hired physician who isn't credentialed yet. You can't bill for a locum tenens unless one of your regular physicians is really away.

2. a physician assistant or certified registered nurse anesthetist who is substituting for another PA or CRNA who is out of town. The locum tenens rules are only for doctors.

Caution: Stick to the 60-day timeframe, or you might find yourself with some denials.

"The '60 continuous days' is calendar days, not worked days, as many people try to interpret it," says Pam Marshall with Northern Colorado Professional Services in Fort Collins. "If a locum tenens worked off and on for 20 total days out of two months, you've still maxed the clock."

Check the times: Keep track of the time the locum tenens is off before the clock starts again, Marshall adds, because payers might have guidelines regarding time spans. Noridian, for example, unofficially suggests waiting two to three months before using the same locum tenens in your practice again.

Locum tenens physicians can be a great solution if one of your doctors is on maternity leave or is away for a long time. But if you have a certified registered nurse anesthetist go away, you may be out of luck.

Remember: Medicare doesn't allow you to bill for the services of a substitute CRNA using your existing CRNA's number. The only thing you can do is to credential the substitute CRNA as quickly as possible so you can bill for his services -- or else eat those costs.

Many coders believe there should be some type of solution for CRNAs when they have to fill in for each other that's comparable to locum tenens. Ideally, these coders and providers would like to see Medicare establish a separate modifier for nonphysician practitioners, similar to Q6. That could help correct the problem practices currently face when a substitute CRNA comes in: The practice must pay the agency for his services, but then the practice doesn't receive any reimbursement.

Across the country, the number of practicing anesthesiologists has dropped for the past few years, while the number of new CRNAs has gone up. But the inability to bill for a substitute CRNA's services is a major drawback, coders say.

Locum tenens guidelines for commercial payers and state Medicaid (Title 19) programs can be very different.

"Several of our commercial payers don't recognize the Q6 and just want claims billed under the absent provider's information," Marshall says. "Some want the locums credentialed by the insurance carrier but don't want the claim billed under the locum's name."

Because of these differences, check with your payers periodically to verify that their guidelines for locums billing haven't changed since the last time you hired a substitute physician.