Pediatric Coding Alert

Obeying the 60-day limit may be trickier than you think

You may have some dangerous misconceptions about  how to properly distinguish locum tenens from reciprocal billing--and about the 60-day time frame that applies to both cases.

To be sure you are appending modifiers Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement) and Q6 (Service furnished by a locum tenens physician) only when appropriate, read on to discover the truths behind these four common myths:

Myth #1: A locum tenens or reciprocal billing physician must provide services consecutively for 60 days in order to time out--and the clock restarts every time there is a break in service.

"If you utilize the service of a substitute doctor and bill under the absent physician's numbers, you have a 60-day clock that starts on the first day of service," says Robert B. Burleigh, CHBME, president of Brandywine Healthcare Services in West Chester, Pa. And whether the locum tenens or reciprocal billing pediatrician provides services "every day for 60 days, or once a week for 60 days--at the end of 60 days, the clock stops."

Don't play games: Some practices will bill a substitute pediatrician's services with Q5 or Q6 for many months or even years using the rationale that the substitute physician worked only once in a while, thereby resetting the clock every time there was a period without services rendered. This is noncompliant billing, Burleigh says.

A simple example should help you understand, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa. She points to the following example based on Medicare policy that private payers may follow:

Suppose your office has a substitute physician provide services to your pediatrician's patients on July 2 and various dates thereafter, including Aug. 30 and Sept. 2. This means your substitute had a 63-day period of continuous services.

Your doctor may not bill for the Sept. 2 services because they occurred after the 60-day period had finished. Instead, the substitute physician must bill for these services in his own name.

Good reason: Medicare instituted the 60-day limit for both locum tenens and reciprocal billing arrangements so it knows exactly who is providing care to its beneficiaries, Burleigh says. If you're going to use a substitute for more than two months, that physician should have his own ID number so you can identify him on your claims. Medicare also favors providers having their own ID numbers because a locum tenens arrangement is a great way for a Medicare-excluded provider to hide behind your physician's number, Burleigh says.

No exceptions: You may be tempted to continue reporting a substitute physician's services as locum tenens or reciprocal billing if she regularly fills in at your practice, but always for a different doctor. While there may be a technical argument that says this is fair use, Burleigh suggests that you should look to Medicare's intent in creating the 60-day rule. If a provider is frequently filling in and providing services to your patients, that provider should have her own number, he says.

Myth #2: Locum tenens physicians can't have their own practice or position--they are strictly physicians "for hire."

"Not true," Burleigh says. There are plenty of locum tenens physicians who have steady work at a practice, he says.

Lesson: Never assume that a substitute physician falls under reciprocal billing rather than locum tenens just because he has a day job. Many physicians decide to moonlight as a locum tenens as a way to make extra money. Medical residents, as well, often find time to work nights, weekends, or holidays as locum tenens providers, Burleigh says.

Example: Your practice manager arranges for a resident at a local hospital to see your pediatrician's patients while she's away for a long Thanksgiving weekend. For any service the resident renders at your clinic, you can and should report the appropriate service codes along with modifier Q6 for a locum tenens provider.

Myth #3: A locum tenens physicians is always used for longer stretches of time, whereas a reciprocal billing arrangement is usually for shorter absences.

The length of time or the type of a physician's absence (vacation, sick time, maternity leave, etc.) has nothing to do with whether the substitute doctor has a locum tenens or reciprocal billing arrangement with your practice, Burleigh says.
 
Pitfall: Don't be tricked into appending modifier Q5 for reciprocal billing just because the substitute doctor is local and is only filling in during your physician's short vacation. Although your physician may be more likely to arrange for a colleague to see his patients in a reciprocal billing arrangement whenever he takes vacations, there is also the possibility that a local doctor would agree to fill the shifts as a locum tenens--and that would merit modifier Q6.

Example: Your physician takes Friday off, and a local doctor agrees to fill in during the afternoon. The substitute doctor treats one of your established patients who comes in complaining of flu-like symptoms, and you code the visit with 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Upon checking with your practice manager, you discover that the substitute physician is in fact working under a locum tenens agreement for the day, so you append modifier Q6 to code 99212 to alert the insurer of the situation.

Myth #4: You can easily distinguish locum tenens from reciprocal billing by the type of payment arrangement or contract your practice has with the substitute physician.

Not exactly. A practice is supposed to have a contract with any locum tenens physician, "but I have seen plenty of locums without a contract," Burleigh says. In addition, payment arrangements for both types of substitute physicians are "totally variable," he adds.
 
"It is common to find a locums paid by the hour, but that is by no means the only way or the main way." And as for reciprocal billing, payment arrangements are "all over the map," Burleigh says.

Often a reciprocal billing provider won't be paid anything for his services, with the understanding that your provider will return the favor--but there's no hard-and- fast rule on this.

Lesson: Don't look to payment arrangements or the presence of a contract as a guide to whether you should append Q5 or Q6. Instead, ask your practice manager or physician about the substitute physician's relationship to your practice--and remember that it's not always a clear-cut answer.