Substitute Physicians – Reciprocal Billing Arrangements

February 10, 2008

The patient’s regular physician may submit a claim, and when assignment is accepted, receive Part B payment for covered visit services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis if the following occur:

  • regular physician is unavailable to provide the visit services,
  • Medicare patient has arranged or seeks to receive the visit services from the regular physician,
  • substitute physician does not provide the visit services to Medicare patients over a continuous period of more than 60 days, and
  • regular physician identifies the substitute physician services by using the modifier Q5 after the procedure code in Item 24d on the CMS-1500 claim form or electronic equivalent.

The patient’s regular physician must keep a record on file for each service provided by the substitute physician, along with the substitute physician’s UPIN number. This record should be available to Medicare on request. It is not necessary to provide this information on the claim form.

If the only substitution services performed in connection with an operation are postoperative services furnished during the period covered by the global surgical fee, they need not be identified on the claim as substitution services. A physician may have reciprocal arrangements with more than one physician. The arrangements need not be in writing.

The term ‘covered visit service’ includes not only a service ordinarily defined as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as ‘incident to’ services. Items and services furnished by the staff of the substitute physician covered as ‘incident to’ his services if billed by him, are still covered if billed by the regular physician. Items and services furnished by the staff of the regular physician covered as ‘incident to’ his services if furnished under his supervision are still covered if furnished under the supervision of the substitute physician.

A continuous period of covered visit services begins on the first day the substitute physician provides covered visit services to Medicare Part B patients of the regular physician. The period ends with the last day on which the substitute physician provides these services before the regular physician returns to work. This period continues without interruption on days when no covered visit services are provided to patients on behalf of the regular physician or when furnished by some other substitute physician on behalf of the regular physician. A new period of covered visit services can begin after the regular physician has returned to work.

Example: The regular physician goes on vacation on June 30, 2002, and returns to work on September 4, 2002. A substitute physician provides services to Medicare patients of the regular physician on July 2, 2002 and at various times thereafter, including August 30 and September 2, 2002. The continuous period of covered visit services begins on July 2 and runs through September 2, a period of 63 days. Since the September 2 services are furnished after the expiration of 60 days of the period, the regular physician is not entitled to bill and receive direct payment for them. The regular physician may, however, bill and receive payment for the services that the substitute physician provides on his behalf in the period July 2 through August 30, 2002.

The requirements for submission of claims under the reciprocal billing arrangements are the same for both assigned and non-assigned claims. These requirements do not apply to the substitute arrangements among physicians in the same medical group when claims are submitted in the name of the group. In this case, the group physician who actually performs the service must be identified.

For a medical group to submit claims for the covered visit services of a substitute physician, who is not a member of the group, the group must enter the modifier Q5 after the procedure code. In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her PIN in Item 24k on the CMS-1500 claim form or electronic equivalent.

Physicians should be aware that use of modifier Q5 by the regular physician (or the medical group, where applicable) certifies that covered visit services were furnished by the substitute physician identified in a record of the regular physician, which is available for inspection, and are services for which the regular physician (or group) is entitled to submit. A physician or other person who falsely certifies any of the above requirements may be subject to possible civil and criminal penalties for fraud.

Locum Tenens Arrangements

It is a longstanding and widespread practice for physicians to retain substitute physicians in their professional practices when they are absent for reasons of illness, pregnancy, vacation or continuing medical education. It is also acceptable for the regular physician to bill and receive payment for the substitute physician’s services as if he performed them himself. The substitute physician generally has no practice of his own and moves from area to area as needed. It is customary for the regular physician to pay the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than an employee. Substitute physicians are generally called locum tenens physicians.

The patient’s regular physician may submit a claim and (if assignment is accepted) receive the Part B payment for covered visit services (including emergency visits and related services) of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices, if:

  • the regular physician is unavailable to provide the visit services,
  • the Medicare beneficiary has arranged or seeks to receive the visit services from the regular physician,
  • the regular physician pays the locum tenens for his services on a per diem or similar fee-for-time basis,
  • the substitute physician does not provide the visit services to Medicare patients over a continuous period of more than 60 days, and
  • the regular physician identifies the services as substitute physician services by entering the HCPCS modifier Q6 (service furnished by a locum tenens physician) after the procedure code in Item 24d on the CMS-1500 claim form or electronic equivalent.

The patient’s regular physician must keep on file a record of each service provided by the substitute physician, along with the substitute physician’s UPIN. This record should be available to Medicare on request. It is not necessary to provide this information on the claim form.

The requirements for the submission of claims under locum tenens billing arrangements are the same for assigned and non-assigned claims.

When a medical group submits claims for the services a locum tenens physician provides for patients of the regular physician, the per diem or similar fee-for-time compensation which the group pays the locum tenens physician is considered paid by the regular physician. Also, a physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may still be considered a member of the group until a permanent replacement is secured. The group should enter the modifier Q6 after the procedure code.

In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her PIN in Item 24k on the CMS-1500 claim form or electronic equivalent. The group must retain a copy of each service provided by the substitute physician, along with the substitute physician’s UPIN number. This record must be made available to Medicare upon request. It is not necessary to provide this information on the claim form.

Physicians should be aware that use of modifier Q6 by the regular physician (or medical group, where applicable) certifies that the covered visit services furnished by the substitute physician are identified in the record of the regular physician which is available for inspection, and are services that the regular physician (or group) is entitled to submit. A physician or other person who falsely certifies any of the above requirements may be subject to possible civil and criminal penalties for fraud.

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