Practice Management Alert

Take control of your vacationing provider's billing by mastering reciprocal billing and locum tenens

The differences between modifiers -Q5 and -Q6 may seem subtle, but your claims will be boldly noncompliant if you choose the wrong one.

When your physician takes vacation time and arranges for a substitute physician to see his patients, you need to inform payers of the situation by appending the proper modifier: -Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement) or -Q6 (Service furnished by a locum tenens physician).

Learn the -Q5 and -Q6 Differences

If you understand the differences between a reciprocal billing arrangement and a locum tenens physician, you will choose the right modifier every time.
 
Reciprocal billing: In this situation, the substitute physician usually has his own practice, and both physicians have agreed to cover for each other during vacations, says Sherry Wilkerson, RHIT, CCS, CCS-P, coding/compliance manager with Catholic Healthcare Audit Network LLC in Clayton, Mo.
 
According to the Medicare Carriers Manual, "a physician may have reciprocal arrangements with more than one physician." And Medicare doesn't require that a reciprocal arrangement be in writing, Wilkerson adds.

Locum tenens: A locum tenens physician is usually an independent contractor who does not have his own practice and moves from area to area as needed, Wilkerson says. The payment arrangement for a locum tenens physician is usually a fixed amount per diem or similar fee-for-time agreement, she says. Medicare requires no such payment terms for a reciprocal billing arrangement.

The time factor: "Medicare defines reciprocal billing to be on an occasional basis," therefore practices usually use locum tenens for longer physician absences, Wilkerson says. The covering physician in a reciprocal billing arrangement is usually not available for longer periods of time because he has his own practice obligations, she says.

Real-life scenarios: If your physician is taking holiday vacation time, you are more than likely dealing with a reciprocal billing arrangement and should append modifier  -Q5 to the substitute provider's claims. Wilkerson says that in her experience, reciprocal billing is for "short-term coverage such as illness, holidays, and short vacations."
 
Locum tenens is more often used for "maternity leave, long-term illness or disability, long vacations, or any time the physician will be gone longer than what would be reasonable under a reciprocal arrangement," she says.

3 Rules Apply to Both -Q5 and -Q6

1. A reciprocal billing or locum tenens arrangement cannot span a continuous period of more than 60 days.

2. Patients must have scheduled an appointment beforehand to receive your physician's services, not the substitute physician's.

3. You should check with each of your non-Medicare payers to see how they would like you to report reciprocal billing and locum tenens services. Although Medicare requires -Q5 and -Q6, other payers may not recognize these modifiers.

Note: For more detailed information on reciprocal billing and locum tenens, refer to the Medicare Carriers Manual, sections 3060.6 and 3060.7, online at www.cms.hhs.gov/manuals/14_car/3b3060.asp#_3060_7.