Locum Tenens and Practice Coverage

The demands of practice can often be daunting.  We know we should take care of ourselves and take a break once in a while.  Getting away is not always practical. Overhead is still present, the staff doesn’t always keep to our schedule because of family obligations, and of course, the patients seemingly want us on call 24/7.  We can hire another doctor to practice in the office with us, but it is hard to find someone that the patients love who practices in the same style as we do. Then, of course, we have government and insurance regulations.  Certification for another doctor for Medicare, PPO restrictions and credentialing can be tedious, especially when we just want them to fill in on a temporary basis.

Locum Tenens

There is a method to have someone come in and substitute for us on a temporary basis.  This can be accomplished whether we want someone on a temporary basis for vacation work or maybe to fill in for us when we are temporarily disabled.  This is known as “locum tenens.”

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Recently, a doctor’s wife told me of an instance when the doctor had a sudden heart attack.  The doctor survived, but he was out of the office for two long months.  The wife informed me that because of his extended absence, both she and their front desk assistant had to go on unemployment before the doctor could start seeing patients again.  This could have easily been avoided!  If only they had used a doctor under “locum tenens.”

Roughly translated from Latin, locum tenens means “to hold a place.”

Not all insurance carriers allow locum tenens doctors.  Medicare has provisions for the acquisition of a locum tenens, as do many Blue Cross carriers.  A locum tenens physician is one who will step in and fill in for a doctor on a temporary basis.  The physician does not have to enroll in the Medicare program.  In fact, to qualify as a locum tenens, all the doctor needs to have is a National Provider Number (NPI) and an unrestricted license to practice in the state where he or she will be working. 

Guidelines for locum tenens in Medicare can be found in the CMS Claims Processing Manual, Publication 100-04, Chapter 1, Section 30.2.11.   Under the guidelines, the locum tenens can fill in for up to 60 continuous days.  If circumstances require the continued use of a locum tenens physician, then a different physician must be brought in for an additional period, not to exceed 60 days.  The result is that the practice can run up to 120 total days if the doctor needs to be absent, such as with a medical disability. An exception to this 60-day rule is for regular physicians who are called to active duty in the armed forces. The time is unlimited.

Restrictions on the use of the locum tenens physician are present if you have the intent to hire the doctor.  The locum tenens is only for a temporary substitution and not to exceed 60 continuous days for any physician.  It would not be used, as an example, to cover peak times, when temporarily expanding services, or to replace a deceased provider.

If you do choose to employ a locum tenens physician, Medicare requires the following documentation:

The regular physician or group must keep a record of each service furnished by the locum tenens, along with his/her NPI. The reason the regular physician cannot provide services should also be included in the record. In the event that Medicare requests it, there should be documentation to substantiate a locum tenens arrangement has occurred. This may be a contract or letter of explanation. All other general principles of documentation apply; the record must verify that the services performed were medically necessary and otherwise covered by Medicare in order for the regular physician to receive Medicare reimbursement.

On the claim form, the regular physician’s (absent physician) NPI number is reported in item 24J on the CMS 1500 claim form or the electronic equivalent.  If the conditions are met, the regular physician submits the professional services under his/her NPI, using the appropriate procedure codes and HCPCS modifier Q6. The regular physician receives any Medicare payment for the service. These requirements are only for Medicare. To determine how private payers reimburse locum tenens services, you should contact the other payers.

If, after returning to work for a brief period of time, the regular physician must be absent again, the same locum tenens physician may be re-hired for a new 60-day period. If a physician is absent longer than 60 days without returning to work, the same locum tenens must be credentialed and enrolled if he or she is going to stay.

In summary:

• The locum tenens physician can only be utilized up to a 60-day continuous period, and, if needed, another physician can be brought in for up to another 60 day period (not more than two periods 120 days total)
• The regular physician must be unavailable.
• The locum tenens must be compensated on a per diem or similar fee for time basis.
• New patients may be seen by the locum tenens, as long as the patient seeks to receive the services from the regular physician.
• A record must be kept of each service provided by the locum physician along with the locum’s physician identification number.
• Claims must contain the modifier ‘Q6’after the procedure code in box 24D of the CMS-1500 form

If circumstances require the physician to be away for an extended period, then the locum tenens provision can lend a practical solution.  If the physician just wants to get away for an extended period and the period is to exceed 120 days, then maybe it’s time to consider retirement.

Dr. Fucinari is a frequent national speaker on compliance, Medicare and ICD-10 coding. For an updated schedule of classes and locations, go to www.AskMario.com.  Dr. Fucinari is the author of several books, including, ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office, available at www.Askmario.com.  Dr. Mario Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant.  For further information on chart audits, compliance audits, manuals or consulting, please contact Dr. Fucinari at Doc@Askmario.com