Locum Tenens Billing: CMS Guidelines Simplified
Locum tenens billing under CMS guidelines can be tricky, especially for Medicare claims. From using the Q6 modifier to adhering to the 60-day rule, compliance is key to avoid denials. Let’s break down the essential CMS rules and how to stay on top of locum tenens billing requirements.
For this post, we’re focusing on CMS’s guidelines for locum tenens. Commercial payers often follow CMS rules regarding billing practices like this. However, if you’re working with non-Medicare payers, always check your specific contract or contact provider relations for clarification. Every payer is different!
Key Takeaways:
- CMS locum tenens allows substitute physicians to fill in temporarily.
- The Q6 modifier must be used when billing under the regular physician’s NPI for locum tenens services.
- Locum tenens services can only be billed for 60 days per year.
- Locum tenens physicians must be independent and not employed by the practice.
- After 60 days, you must start billing under the substitute physician’s NPI.
Now, let’s explore the details of CMS locum tenens guidelines and how to stay compliant when using this practice in your medical office.
What is Locum Tenens?
Put, locum tenens allows a substitute physician to fill in for a regular physician during an absence. This is important when a regular physician isn’t available due to things like:
- Pregnancy
- Vacation
- Illness
- Military deployment
- Continuing education
The key is that the regular physician is unavailable and in good standing with Medicare or any payer they bill. The substitute physician provides services in their place, and certain billing requirements must be met.
Key Requirements for Using Locum Tenens
Here are some basic CMS locum tenens guidelines you need to follow to use a substitute physician:
1. The Regular Physician Must Be Unavailable
First, the regular physician (or practitioner) must be completely unavailable. Whether on vacation, sick, or leave, they can’t be on the premises or available to provide care.
2. Patients Must Be Regular Patients of the Absent Physician
The patients seen by the locum tenens doctor must be patients who would have been seeking care from their regular doctor if they were available. So, the locum tenens physician is acting purely as a temporary substitute.
3. Locum Tenens Must Be Paid Per Diem
CMS requires that locum tenens physicians be compensated per diem—meaning they’re paid by the day or service rather than salaried.
4. The 60-Day Rule
This is one of the big ones. You can only use locum tenens services for a maximum of 60 days per year. And yes, that includes weekends.
- Example: If the locum tenens starts seeing patients on January 1st, the last day they can provide services under the regular physician’s NPI is March 1st (60 days later). After that, you’d have to start billing using the locum tenens physician’s NPI and tax ID.
Remember, the 60-day period can be consecutive or spread out over multiple stretches, but it’s cumulative—once you hit those 60 days, you’re done for the year.
Billing Locum Tenens Services
Now that you’ve mastered the basics let’s discuss billing locum tenens services. This is where people can get tripped up, but as long as you follow these rules, you’ll be good.
1. Use Modifier Q6
When billing for services provided by a locum tenens physician, you’ll bill using the regular physician’s NPI and tax ID—just as if the regular physician were seeing the patient. However, to indicate that this is a locum tenens situation, you must add modifier Q6 to the claim.
The Q6 modifier signals to CMS or any other payer that a substitute physician was filling in, and you’re still billing under the regular doctor’s credentials.
2. The Practice Cannot employ the Locum Tenens Physician
The locum tenens physician cannot already be employed by or affiliated with the practice. They must be completely independent practitioners filling in temporarily.
If your practice already employs the substitute physician, they wouldn’t be considered locum tenens. In that case, you would bill using their NPI and tax ID.
3. Stop Billing Under the Regular Physician After 60 Days
As mentioned, once the 60 days are up, you must stop billing under the regular physician’s NPI. On Day 61, if the substitute physician still sees patients, you must start billing under their NPI and tax ID number.
Why Modifier Q6 and the 60-Day Rule Matter
If you’re wondering why these rules exist, it’s all about keeping things above board and transparent. Medicare and other payers must know when a regular physician isn’t providing services; the Q6 modifier helps flag that.
The 60-day limit ensures that locum tenens physicians are only used temporarily. Once you go beyond that, you’re entering the realm of needing to credential the substitute doctor with Medicare and bill under their credentials.
What About Commercial Payers?
As mentioned, commercial payers often follow CMS locum tenens guidelines, but not always. Some payers might have different rules around how long you can use a substitute physician, how to bill them, or even whether they allow locum tenens.
Always:
- Read your contract with commercial payers.
- Check their provider guidelines on locum tenens billing.
- Contact provider relations if you’re unsure.
Important Takeaways
To recap, the most important things to remember about CMS locum tenens guidelines are:
- The regular physician must be unavailable and cannot be on-site.
- Patients must seek the care they usually get from a regular physician.
- You must use modifier Q6 when billing under the regular physician’s NPI.
- The locum tenens must be an independent substitute—not already employed by the practice.
- You can only bill for locum tenens services for a maximum of 60 days per year.
Common Billing Mistakes with Locum Tenens
Mistake 1: Forgetting the Q6 Modifier
This is a big one and happens more often than you’d think. If you’re billing for a locum tenens physician but forget to use the Q6 modifier, it’s almost guaranteed your claim will be flagged—or worse, denied. The Q6 modifier is your way of letting Medicare know that the regular doctor didn’t provide this service but by a temporary substitute.
Always double-check your billing entries to ensure the Q6 modifier is in place whenever you use locum tenens services.
How to avoid it:
- Set up a reminder or a system alert in your billing software to flag any claims where locum tenens are being used. This way, you won’t forget to add the Q6 modifier.
Mistake 2: Exceeding the 60-Day Limit
Another pitfall is miscalculating the 60-day rule. Remember, the 60 days can be consecutive or non-consecutive, but they count the same. You can spread out the days, but when you hit day 61, you can no longer bill under the regular physician’s NPI using the Q6 modifier.
How to avoid it:
- Keep a detailed calendar or log of when your locum tenens starts and stops seeing patients.
- A tool like a shared Google Calendar could help your entire practice track those 60 days across multiple locum tenens practitioners, making sure you don’t accidentally go over.
Here’s an example of how it can be tracked:
| Locum Tenens Doctor | Start Date | End Date | Total Days Used |
|---|---|---|---|
| Dr. Smith | Jan 2, 2024 | Feb 28, 2024 | 58 days |
| Dr. Taylor | Mar 15, 2024 | Mar 20, 2024 | 5 days |
| Dr. Johnson | Apr 5, 2024 | Apr 7, 2024 | 3 days |
This log ensures you’re not exceeding the 60-day limit, including weekends!
Mistake 3: Locum Tenens Already Affiliated with the Practice
A locum tenens physician can’t already be part of your practice. If they are already credentialed or assigned to your tax ID, you can’t bill for their services using the Q6 modifier. They must be independent, unaffiliated physicians to qualify as locum tenens under CMS rules.
How to avoid it:
- Ensure the locum tenens physician hasn’t been reassigned to your practice by Medicare or another payer. You must bill under their NPI and tax ID if they are already part of your practice.
Organizing Multiple Locum Tenens Physicians
Keeping things organized can become challenging if you manage multiple locum tenens doctors in a busy practice. Here are some tips to help streamline the process:
Tip 1: Use Practice Management Software
Most billing software allows you to add special flags or alerts for locum tenens services. Use these features to track when you’ve hit the 60-day mark and ensure the Q6 modifier is applied.
Tip 2: Create a Shared Tracking Document
A simple Google Sheet or Excel document that tracks locum tenens doctors and their active days in your practice can be incredibly useful. This is particularly important if different people in your practice handle scheduling, billing, and compliance.
Here’s a template you could use:
| Doctor | Start Date | End Date | Total Days Used | Q6 Modifier Applied | Notes |
|---|---|---|---|---|---|
| Dr. Smith | Jan 1, 2024 | Feb 28, 2024 | 58 days | Yes | Consecutive days |
| Dr. Taylor | Mar 1, 2024 | Mar 15, 2024 | 10 days | Yes | Weekend included |
| Dr. Johnson | May 1, 2024 | May 10, 2024 | 9 days | Yes | Off and on coverage |
Keeping a running tally ensures everyone in the office stays on the same page about how many days the locum tenens physician has left before hitting the 60-day limit.
Exceptions and Special Cases
A few special cases where the CMS locum tenens guidelines may need a closer look. Here’s what to keep in mind:
Emergency Situations
In emergency cases—such as a physician becoming ill unexpectedly—CMS allows locum tenens billing to begin immediately. However, the same 60-day rule still applies, even in emergencies. Make sure to document the reason for the locum tenens in the patient’s records in case of an audit.
Physician Termination
If a regular physician leaves the practice permanently (for example, retirement or resignation), you cannot use a locum tenens to fill their role beyond 60 days. After the 60-day window, the substitute physician must be credentialed under your practice and billed under their own NPI.
Military Deployment
When a physician is deployed for active military duty, the locum tenens physician can only cover for 60 days. The regular rules apply once the 60 days are up, and billing must shift to the substitute physician’s NPI.
Communication with Payers
Don’t assume every payer follows CMS guidelines regarding locum tenens. While commercial payers often model their rules after CMS, there are exceptions. Here’s how to stay on top of things:
- Check Your Contracts: If you have a contract with a commercial payer, review it to see if it specifies rules about using locum tenens. Sometimes, payers have shorter or longer timeframes or may not allow locum tenens billing.
- Contact Provider Relations: If you’re unsure, call the provider relations team for that payer. They can confirm whether they follow CMS locum tenens guidelines or have their own rules.
FAQ
What is Locum Tenens?
Locum tenens refers to temporary substitute physicians who fill in for regular doctors during their absence. This arrangement ensures continuity of care when a physician is unavailable for reasons like vacation, illness, military deployment, or continuing education. Locum tenens physicians help maintain patient services without disruption.
What Are the Key CMS Guidelines for Locum Tenens?
CMS guidelines for locum tenens include using the Q6 modifier when billing under the regular physician’s NPI, limiting locum tenens services to 60 days per year and ensuring that locum tenens physicians are independent and not employed by the practice. These rules help prevent billing issues and ensure compliance with Medicare standards.
How Do I Bill Locum Tenens Services Under CMS Guidelines?
To bill locum tenens services under CMS guidelines, use the regular physician’s NPI and tax ID and add the Q6 modifier to indicate a substitute physician. Ensure that billing does not exceed the 60-day limit per year. After 60 days, switch to billing under the locum tenens physician’s NPI and tax ID.
What is the Q6 Modifier and When Should It Be Used?
The Q6 modifier is used when billing for services a locum tenens physician provides under the regular physician’s NPI. It signals to CMS and other payers that a substitute physician is filling in temporarily. Using the Q6 modifier correctly helps prevent claim denials by clearly indicating the nature of the service.
What is the 60-Day Rule in Locum Tenens Billing?
The 60-day rule limits locum tenens services to 60 days per year. This period can be consecutive or spread out throughout the year. Once the 60 days are reached, billing must shift to the substitute physician’s NPI and tax ID. This rule ensures that locum tenens are used only temporarily.
Can I Employ a Locum Tenens Physician in My Practice?
No, locum tenens physicians must be independent and not employed by the practice. Under CMS guidelines, physicians who are already employed or affiliated with the practice do not qualify as locum tenens. Such physicians should be billed using their NPI and tax ID instead of the regular physician’s.
How Do Commercial Payers Handle Locum Tenens Billing?
While commercial payers often follow CMS locum tenens guidelines, they may have specific rules. Reviewing contracts with commercial payers, checking their provider guidelines, and contacting provider relations for clarification is essential. Always verify each payer’s requirements to ensure accurate billing practices.
What Are Common Billing Mistakes with Locum Tenens?
Common billing mistakes include forgetting to use the Q6 modifier, exceeding the 60-day limit, and employing locum tenens physicians. These errors can lead to claim denials or incorrect payments. To avoid them, set up reminders, track locum tenens days diligently, and ensure all billing entries are accurate.
How Can I Track Multiple Locum Tenens Physicians?
To effectively manage multiple locum tenens physicians, use practice management software with special flags or alerts for locum tenens services. Additionally, create a shared tracking document like a Google Sheet or Excel file to log each physician’s active days, modifier usage, and remaining locum tenens days. This ensures compliance with the 60-day rule.
Are There Exceptions to the CMS Locum Tenens Guidelines?
Yes, there are exceptions for emergencies where a regular physician becomes unexpectedly unavailable. Locum tenens billing can begin immediately in such cases, but the 60-day rule still applies. Additionally, if a physician leaves the practice permanently, locum tenens cannot replace them beyond the 60-day limit without proper credentialing.
Final Thoughts
Navigating CMS locum tenens guidelines is essential for maintaining compliance and ensuring smooth billing processes in your medical practice. By understanding and adhering to key requirements—such as using the Q6 modifier, respecting the 60-day limit, and ensuring locum tenens physicians remain independent—you can effectively utilize temporary physicians without encountering billing issues or claim denials.
Build robust tracking systems and leverage practice management software to monitor locum tenens usage to avoid common mistakes. Regularly reviewing your billing practices and staying informed about CMS and commercial payer requirements will safeguard your practice against potential pitfalls.
Implementing these guidelines ensures proper reimbursement and maintains the continuity of care your patients expect. Stay proactive, keep your billing accurate, and make the most of locum tenens solutions to support your practice efficiently.