Billing Medicare, Medicaid for Substitute Physician Services

Substitute physicians usually assume professional practices in the absence of a regular physician for reasons such as illness, pregnancy, vacation, or continuing medical education.

The substitute physicians generally have no practice of their own and move from area to area as needed. Medicare rules require that a substitute physician cannot provide services for another physician for longer than 60 continuous days at a time (or more if the other physician has been called or ordered to active duty as a member of a reserve component of the armed forces see – see section 1842(b)(6)(D) of the Social Security Act). The regular physician generally pays the substitute a fixed per-diem amount, with the substitute having the status of an independent contractor rather than an employee.

The regular physician then submits the claim using the Q6 modifier (services furnished by a substitute physician). Additionally, the regular physician must keep on file a record of each service provided by the substitute along with the substitute's National Provider Identifier. Find all the details in the Medicare A/B Reference Manual, 30.2.11 Payment Under Fee-for-Time Compensation Arrangements (formerly referred to as locum tenens arrangements).

Under reciprocal billing arrangements, a patient's regular physician may submit a claim and receive payment for the services arranged to be provided by a substitute physician on an occasional basis, for up to 60 continuous days (or more if called to active duty). The regular physician should identify the service as substitute physician services and bill Medicare with the Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement).

Medicaid also covers reciprocal and substitute physician services. Reciprocal services are limited to a continuous period no longer than 14 days and are billed with modifier Q5. Substitute (locum tenens) services are limited to 90 days (or more if the regular physician is called to active duty) and are billed using modifier Q6. The locum tenens arrangement must be in writing. See 9.2.3 Substitute Physician in the Texas Medicaid Provider Procedures Manual for details.

For commercial payers, the requirements may vary, making it necessary to determine billing procedures on a payer-by-payer basis.

 

 

Last Updated On

May 28, 2019