Urology Coding Alert

Learn how locum tenens actually works before appending Q5 and Q6 whenever you bill under another provider’s NPI.

When you have a new urologist join your practice, the wait to get the provider credentialed so you can bill Medicare for him can be frustrating. If you think you can just report the new doctor’s service under an existing physician’s ID number and append the locum tenens modifier to it to seek reimbursement, you are setting your practice up for disaster.

Reality: You should never bill a non-credentialed urologist’s services as locum tenens just to get paid. Locum tenens is designed to represent services performed "in the absence of the regular physician," according to chapter 1 of the Medicare Claims Processing Manual.

The scenario: Many practices have grown frustrated at wait times for Medicare credentialing when they hire a new physician, so they simply report the new physician’s service as if it was performed by a locum tenens doctor, but that goes against the original intent of the locum tenens rules.

Some practices are billing this way, and they may even say they heard the advice at a conference. But you have to go back to the original source -- chapter 1 of the

Medicare Claims Processing Manual -- which indicates that locum tenens applies to cases where the regular physician is absent due to illness, pregnancy, vacation, or continuing medical education, and the locum tenens physician fills in for him during his absence.

Plus: One of the stipulations of locum tenens is that you pay the doctor taking over for you on a per-diem basis. So if you’re just billing a new physician as a locum tenens, not only are you billing incorrectly, but you are making a mistake in your payment structure as well.

What is Locum Tenens?

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," says Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. "Also, you should include the NPI of the temporary doctor in box 23 on the CMS-1500 form," she adds.

You can bill for a locum tenens for 60 continuous days. In rare cases when a physician is on active duty in the Armed Forces, Medicare may allow you to bill locum tenens services beyond the 60-day limit, but in most other cases Medicare Administrative Contractors (MACs) are very strict with the timing.

Don’t Just Leave Off Modifier Q6

In some cases, practices will bill the new physician’s services under an existing doctor’s NPI and just leave off the Q6 modifier, acting as if the other doctor personally performed the service. Most of the time, however, this inappropriate billing practice will eventually catch up with you, so you’re better off reporting things based on the regulations, says Chandra L Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC.

In fact, the OIG addressed this issue by offering the following example of "misrepresentation of services to the Federal health care programs in the Oct. 5, 2000 Federal Register: "When the practice bills for a service performed by Dr. B, who has not yet been issued a Medicare provider number, using Dr. A’s Medicare provider number. Physician practices need to bill using the correct Medicare provider number, even if that means delaying billing until the physician receives his/her provider number."

To read the Medicare Carrier’s Manual’s section on locum tenens billing, visit http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf and scroll to section 30.2.11.