Effective Date: 10/02; Rev. 10/04, 11/07, 7/10 POLICY: Whenever a Physician Practice (as defined below) uses a Substitute Physician (as defined below) for coverage for an absent physician, the practice will comply with the terms of this policy for services provided to Medicare beneficiaries. SCOPE: IHS system wide. All IHS and affiliate Physician Practices. BACKGROUND: The purpose of this policy is to ensure compliance with Medicare regulations for occasions when the services of a Substitute Physician are necessary to meet the physician coverage needs of a Physician Practice. These needs may occur as a result of a regular physician s absence for many reasons such as due to illness, pregnancy, vacation, or continuing medical education. This policy only applies to substitute services between physicians, and does not apply to substitute services between physicians and non-physician practitioners or between non-physician practitioners. PROCEDURES: 1. Definitions. 1.1 Locum Tenens Physician means a physician who: 1.1.1 Generally has no practice of his/her own; 1.1.2 Is paid by the regular physician or group practice on a per day or payment for time basis; and 1.1.3 Is an independent contractor rather than an employee. For purposes of this policy, in order to qualify as an independent contractor, the Locum Tenens Physician must be a member of a group medical practice unrelated to the group medical practice requesting the Substitute Physician services or be provided by a locum tenens agency. 1.2 Physician Practice includes all IHS facilities that provide professional physician services. Page 1 of 6 07/10
1.3 Reciprocal Arrangement means an informal arrangement under which physicians who are not members of the same group practice cover for each other. 1.4 Substitute Physician means a physician who fills in for a regular physician during the regular physician s absence. 2. General Rule. Every physician who provides services to Medicare beneficiaries as a Substitute Physician must either qualify as a Locum Tenens Physician (see Section 3 below), or be employed by the IHS entity for which the physician is providing services (see Section 4 below), or provide services under a Reciprocal Arrangement (see Section 5 below). 3. Use of Locum Tenens Physicians. 3.1 Time Limitation. 3.1.1 The Locum Tenens Physician cannot provide covered visit services to Medicare patients over a continuous period of longer than 60 days. 3.1.2 A continuous period begins with the first day on which the Locum Tenens Physician(s) provides covered visit services to Medicare patients of the regular physician and ends on the last day on which the Locum Tenens Physician(s) provides these services before the regular physician returns to work. 3.1.3 The continuous period includes days on which no covered visit services are provided to patients or are furnished by some other substitute physician on behalf of the regular physician. 3.1.4 A new 60-day time period can begin, if indicated, after the regular physician has returned to work and rendered a covered visit to a Medicare patient. 3.2 Billing for Services Performed by a Locum Tenens Physician. 3.2.1 A claim will be submitted for the covered visit services provided by a Locum Tenens Physician to a Medicare patient providing the patient intended to seek services from the regular physician who is unavailable. 3.2.2 Covered visit services are ordinarily characterized as a covered physician visit and any other covered items and services furnished by the Locum Tenens Physician or others, as incident to his/her services. Page 2 of 6 07/10
3.2.3 Medicare requires all services of the Locum Tenens Physician meeting the requirement of this policy be billed using the name and provider identification number (NPI or PTAN) of the absent regular physician. 3.2.4 For Medicare claims, a Q6 modifier should be reported with each service/procedure performed by the Locum Tenens Physician or incident to his/her services. 3.2.5 The requirements for the submission of claims under locum tenens billing arrangements are the same for assigned and non-assigned claims. 3.3. Documentation Requirement. The regular physician or group practice must keep on file a record of each service provided to a Medicare patient by the Locum Tenens Physician including the Locum Tenens Physician s NPI or PTAN. This record will be made available to the Medicare Administrative Contractor upon request. 3.4 Medical Group. 3.4.1 A Physician Practice may submit claims to Medicare for a Locum Tenens Physician that is providing services to patients of a regular physician who is a member of the group. 3.4.2 According to Medicare guidelines, 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 obtained (within the 60-day limitation). 3.4.3 Billing for the services of a Locum Tenens Physician pursuant to the practice outlined in 3.4.2 above requires the written authorization of the departing physician whose NPI or PTAN will be used for billing. The signed form should be retained for ten years. A sample Medicare Locum Tenens Permission Form is attached as Attachment A. 3.5 Use For Billing Only. The locum tenens billing rules only allow the Locum Tenens Physician to use the billing number of the absent physician. The Locum Tenens Physician must have their own medical staff privileges and sign orders in their own name. 3.6 Policy Compliance Monitoring. If a Locum Tenens Physician is used, the Physician Practice will perform periodic reviews to assure compliance with this policy. Page 3 of 6 07/10
4. Use of Employed Physicians. 4.1 4.2 Time Limitation. An employed physician may cover for, or provide services in place of, an absent physician indefinitely, provided both physicians are employed by the same group medical practice. Billing for Services Performed by the Employed Physician. All claims for services performed by an employed physician shall be billed using the NPI or PTAN of the employed physician. 5. Reciprocal Arrangements. 5.1 If an employed physician is not a member of the same group as the absent physician, a Reciprocal Arrangement is permitted by Medicare. 5.2 Time Limitation. As with a locum tenens arrangement, there is a time limitation. The time limitation requirements outlined in Section 3.1 apply to Reciprocal Arrangements. 5.3 Billing for Services Performed under a Reciprocal Arrangement. 5.3.1 A claim will be submitted for the covered visit services provided by a physician under a Reciprocal Arrangement to a Medicare patient providing the patient intended to seek services from the regular physician who is unavailable. 5.3.2 Covered visit services are ordinarily characterized as a covered physician visit and any other covered items and services furnished by the physician or others, as incident to his/her services. 5.3.3 Medicare requires all services of the physician meeting the requirement of the policy be billed using the name and NPI or PTAN of the absent regular physician. 5.3.4 For Medicare claims, a Q5 modifier should be reported with each service/procedure performed by the physician or incident to his/her services. 5.3.5 The requirements for the submission of claims under Reciprocal Arrangements are the same for assigned and non-assigned claims. 5.4 Documentation Requirement. The regular physician or group practice must keep on file a record of each service provided to a Medicare patient under a Reciprocal Arrangement including the physician s NPI or PTAN. This record will be made available to the Medicare Administrative Contractor upon request. Page 4 of 6 07/10
6. Application to non-medicare Payers. Medicaid and most other payers permit use of substitute physicians as outlined in this policy; one significant exception is that they will NOT pay for services performed by a substitute physician covering for a physician who is no longer employed by the practice. Best practice is to confer with these payers for specific guidance on use of substitute physicians. /s/ William B. Leaver William B. Leaver IHS President REFERENCES: Medicare Publication 100-4, Chapter 1, 30.2.10 and 30.2.11. Page 5 of 6 07/10
ATTACHMENT A Title: Use of Substitute Physicians MEDICARE LOCUM TENENS BILLING PERMISSION FORM I,, M.D./D.O., a physician who has effected a reassignment of Medicare benefits to (hereinafter known as ) under Medicare Claims Processing Manual, Publication 100-4, Chapter 1, Section 30.2.6, am or will be terminating or have terminated employment with the aforementioned employer effective, 20. Therefore, I hereby grant permission to to utilize my Medicare provider NPI,, to bill for services provided by locum tenens physicians according to the locum tenens rules set forth in the Medicare Claims Processing Manual, Publication 100-4, Chapter 1, Section 30.2.11, which will not exceed 60 days from the first date the locum tenens physicians provide covered services in my absence. Accepted by: (Printed Name) (Signature) (Date) Page 6 of 6 07/10