August 10th, 2015
It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” doctor. When completing the CMS 1500 claim form, do they use their doctor’s name and NPI, or do they use the name and NPI of the covering doctor who actually saw and treated the patient? And which modifier is correct, Q6 Services furnished by a locum tenens physician or Q5 Services furnished by a substitute physician under a reciprocal billing arrangement?
A substituting doctor is really just a proxy and functions as if the regular doctor were present. For most payers, the substitute physician does not need to be credentialed with the plan, but he or she must possess an unencumbered license in the same specialty. If the temporary doctor is hired on, then Medicare (and presumably most private plans) would require the new doctor to become enrolled before submitting claims. Temporary doctors may not be used indefinitely, CMS limits locum tenens to 60 days, and most other payers probably have similar guidelines.
If the fill-in doctor was hired from the outside, he or she should be paid a per diem or on a fee for time basis as an independent contractor and the –Q6 modifier would apply. “Locum tenens” is latin for “to hold the place of ”, or more plainly, a “fill-in”. When the covering physician is a permanent part of the office (under the same tax ID), this may constitute a reciprocal billing arrangement, and the –Q5 modifier would apply.
- Use modifier -Q5 or -Q6 in box 24d of the CMS-1500 form for each line item in the claim. Append the modifier for each line item service.
- Enter the regular physician’s national provider identifier (NPI) in box 24J of the CMS-1500 form.
- Add the NPI and name of the locum or reciprocal physician in the notes line of the CMS 1500 form. This is not mandatory, but it may be helpful.
- Track the locum’s NPI, his or her services, and the calendar dates the locum provided services in case a carrier requests this information.
- Note that, in either case, the payment goes to the regular physician.
Reference: Medicare Claims Processing Manual, section 30.2.10 and 30.2.11