Presenting Problem

Some doctors fail to code properly for a temporary doctor who is covering an office, or for mutual coverage with a colleague.

History/Subjective

It is a common practice for doctors in solo practice to find someone to "cover" for them while they are away from the office for a temporary or extended period of time.

During such times, the billing staff often wonders how to bill correctly. When completing the 1500 claim form, do they use their doctor’s name who is on vacation or disabled, or do they use the attending/visiting/coverage doctor who actually saw and treated the patient? Whose provider number really goes on the claim form?

Objective Findings

This concept and practice coverage for temporary purposes has been around for many decades. Such temporary doctor relationships are a legal technical term called Locum Tenens. Webster’s Collegiate dictionary definition is: "a temporary substitute, especially for a doctor or member of the clergy...one holding the place is locum tenency." Accordingly, such a substituting doctor is really just a proxy for and functioning as if the regular doctor was present.

There is a modifier to express such events and unusual arrangements from level II modifiers by HCPCS. (See your ChiroCode DeskBook.)

  • Q6 Service furnished by a locum tenens physician.
  • Q5 Services furnished by a substitute physician under a
    reciprocal billing arrangement.

Assessment

-Q5 expresses typical weekend coverage events between doctors. -Q6 expresses events such as the temporary absence, disability or death of the practicing doctor. Accordingly such a modifier code expresses the encounter properly. Some might argue that it is wrong by not expressing the actual person who performed the service. About 2 decades ago, Medicare purists (who probably never worked in the real practitioner world) tried to do away with such locum tenens arrangements and required the performing doctor to use their number on the claim form. Candidly, that initiative "really hit the fan" of reality. Affected doctors and clinics let congress and CMS (HCFA then) know why that was a stupid policy. There was an uproar and a revolt. The healthcare planners reaped the whirlwinds. Within a few months, that bad initiative was reversed and abandoned. All good payers who use the HIPAA code sets understand and use the level II modifiers. Most performing practitioners could be required to have their actual National Provider Number shown in box 24J on the 1500 claim form.

Recommendation/Plan

When a temporary doctor is covering the office, append the modifier -Q6, for "Service furnished by a locum tenens," or -Q5, for "Services furnished by a substitute physician under a reciprocal billing arrangement." Be alert to any requirements that might mandate the performing doctor’s NPI in box 24J. Contact your payers directly for further instructions and requirements regarding locum tenens coverage.