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Part Four: Locum Tenens Billing – Q6 Modifier (YES or NO)?

Part Four: Locum Tenens Billing – Q6 Modifier (YES or NO)?

Ah, the debate on using Modifier Q6 (aka billing for services furnished by a locum tenens physician) rolls on. Much like the wording for an amendment on an election ballot, understanding the issue at hand to confidently give an outright “yes, go for it” or “no, don’t do it” answer is difficult to come by.

No matter what type of health system you represent, the topic of whether or not you can bill for a locum tenens physician is almost guaranteed to come up at one point or another. The CMS (Center for Medicare & Medicaid Service) guidance is a bit murky on the subject and causes a great deal of confusion; especially for private practices who don’t often use locum providers. Even if you have used locums extensively, you’ll still find a broad range of opinions. The best detailed direction comes from the CMS itself at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1486CP.pdf.

The bullet points below cover the readily published instances and guidelines on the utilization of the Q6 modifier in the replacement of an existing physician; temporarily or permanently.  These guidelines apply to Medicare and Medicaid and may not be recognized by commercial payers. You will need to check with each payer to be certain how to code appropriately.

In order to use the Q6 modifier, the following conditions must apply:

  • The regular physician is unavailable to provide services to the patient.
  • The locum tenens is paid for his/her services on a per diem or similar basis (can be through an agency.)
  • The locum is used to provide short term coverage lasting up to 60 days maximum.
  • Only exception of the 60 day rule for a substitute physician is in the case of extended active military duty for the regular physician.
  • Existing physician (the one being covered for,) cannot have been gone for more than 90 days.
  • Cannot use another physician to extend coverage at the end of 60 days.
  • Q6 is not applicable if there is/was not initially a regular physician (as in the case of an expansion.)
  • The physician seeing the patient is not in practice for themselves, or employed as part of another practice.
  • Q6 does not apply to Nurse Practitioner or Physician Assistant services.

If these conditions are met, you can bill for the locum professional services using the absent providers NPI in Box 24 of the CMS-1500 form. You must also use modifier Q6 in box 24D of the CMS-1500 form for each line item service on the claim to indicate that this service was performed by a locum tenens.

Hospital provided services as a hospital outpatient (provider based clinic,) are billed using the UB-04.

For private/commercial payers you may be able to use the Q6 modifier, as most will not allow any back billing option. Many (but not all) of the payers allow for the Q6 and follow most CMS guidelines. They will however, require the physician to be credentialed or enrolled quickly to be eligible. Keep in mind there have been instances where commercial payers refuse to accept a full enrollment when aware that the physician is being used as a locum tenens.

The latest CMS determination contradicts many of the websites (and even some legal opinions,) that you can select another locum at the end of the first 60 day period and continue with another 60 days of Q6 modifier billing. I was personally shocked when I realized this because that was my understanding for years as well. CMS did rule however that since it is a “covering for” situation, if the physician did not end up returning, CMS would need to be notified and they would suspend participation. Therefore, 60 days is the maximum no matter how many locums you use. That is different if the original doctor came back and then went out again (even for one day.) It’s been a major problem since most of the insurers follow lockstep with CMS.

When Q5 (services furnished by a substitute physician under a reciprocal billing arrangement,) and Q6 were initially designated, it was for much shorter periods of time like where the doctor went fishing for a month, or had surgery and needed someone to briefly cover his practice. Now, most hospitals are using locums to cover a resignation (replacement taking 180-300 days) or for service expansions (like opening a new urgent care or general surgery call.) To the dismay of many of these hospitals, this was never the intention of locums and billing with modifiers. Again, the only exception to the 60 day rule is in the event of military deployment; where you can bill almost indefinitely.

Currently the best course of action is to apply for PAR (participation) status with each payer, but this is an ongoing challenge with locums because of the short time frame. Most of it is urgent and the shortest time to get a PAR is with CMS (who allow back billing for 30 days prior to the effective participation date) at approximately 25-30 days. The other commercial payers are more than 60-120 days to PAR. So as you can see, the issue is huge since the hospital or group is always leaving revenue on the table.

Depending on the specific payer mix, there is an opportunity (at least for outpatient/office visits) to use other physicians for the commercial payers and have the locum see the Medicare, Medicaid, and Tricare patients since they can back bill.

It is very helpful to keep the same locum for long-term and to obtain the payer applications, medical staff credentialing, and provider NPI and CAQH numbers as quickly as possible so there is minimal delay in getting them PAR with payers.

Finally, whether for government or commercial payers, it is imperative to keep detailed records of all services provided by a locum tenens. This includes keeping your agency confirmation letters in a file to ensure that the service dates align with the assignment dates. It will allow you to prove that they were rendered under the aforementioned conditions should there be an audit.

Arlene Macellaro is the VP of Business Development and Client Relations for All Star Recruiting. She can be reached at AMacellaro@allstarrecruiting.com.

"When I was initially contacted by All Star, I had already been approached by several companies and presented to quite a few opportunities so I didn't think I needed to speak to another firm. What I didn't count on was All Star having another eight positions which other agencies didn't have. Now I'm happily working at one of the options they offered. Thanks!"
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