Understanding the difference between Locums Tenens and Reciprocal
Written by: Natasha Timberlake, BSHCM, CRCR, CPC, COC, CPMA, CHONC, CPC-I, CEMA
One of the most complex parts of writing an article is deciding where to begin, especially when dealing with a subject or specialty in which we have less experience. However, the best part of writing an article is the opportunity to research and continue learning. One of the key elements to success in auditing is researching, reviewing guidelines, and understanding rules and regulations that may pertain to a certain specialty or scenario.
Most coders and auditors, myself included, may know the definition of Locum Tenens and Reciprocal for E&M services and physicians. Still, we may not understand it clearly because we rarely encounter these types of services. With the opportunity to write this article, I learned more about the similarities and differences between Locum Tenens and Reciprocal physician services, what they entail, and the prospect of sharing the information with you all.
Definitions and Guidelines
Locum Tenens
According to CMS (Centers for Medicare and Medicaid Services):
“The substitute physician often has no practice of his/her own and may move from area to area as needed. A physician may have reciprocal arrangements with more than one physician, and the arrangements need not be in writing.”
— CMS, April 4, 2008
The American Academy of Family Physicians (AAFP) elaborates:
“Normally, the practice or hospital contracts with a third party, a locums company, which keeps a file of physicians who do locum work and have appropriate state licenses. The locums company usually supplies the physician with malpractice insurance, covers travel expenses, and pays an hourly rate for the assignment.”
— Dr. William Cushing, MD, MBA, 1999
Reciprocal Billing
Noridian Medicare clarifies:
“The term ‘locum tenens,’ which has historically been used in the CMS Internet Only manual to mean fee-for-time compensation arrangements, is being discontinued because the title of section 16006 of the 21st Century Cures Act uses ‘locum tenens arrangements’ to refer to both fee-for-time compensation arrangements and reciprocal billing arrangements.”
— Noridian Medicare, April 2, 2024
Medicare Regulations and Billing Procedures
Medicare jurisdictions such as CGS, Noridian, Palmetto, and Novitas, to name a few, seem to have the same coverage determinations for Locum Tenens and Reciprocal. Even though they are under the same Medicare umbrella, it’s imperative to follow the specific jurisdiction where services were rendered, especially because there may be slight differences regarding these services. I also recommend reviewing the commercial and Medicaid payer guidelines because the qualifications may differ slightly.
Per CMS, regulations and guidelines must be followed to correctly bill Locum Tenens and Reciprocal. Below is information from the Medicare Claims Processing Manual. The sections are 30.2.11—Payment Under Fee-For-Time Compensation Arrangements (formerly referred to as Locum Tenens Arrangements)—Claims Submitted to A/B MACs Part B and 30.2.10—Payment Under Reciprocal Billing Arrangements—Claims Submitted to A/B MACS Part B.
Locum Tenens:
The regular physician for physicians’ services and services furnished incident to such services that are provided by a substitute physician during the absence of the regular physician where the regular physician pays the substitute on a per diem or similar fee-for-time basis, and certain other requirements are met.
A patient’s regular physician or physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services of a substitute physician or physical therapist, if:
- The regular physician or physical therapist indicates that a substitute physician or physical therapist provided the services under a fee-for-time compensation arrangement meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area) after the procedure code.
Reciprocal:
The regular physician for physicians’ services and services furnished incident to such services that are provided to the regular physician’s patients by another physician on an occasional reciprocal basis and certain other requirements are met.
A patient’s regular physician or physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services of a substitute physician or physical therapist, if:
- The regular physician or physical therapist indicates that the services were provided by a substitute physician or physical therapist under a reciprocal billing arrangement meeting the requirements of this section by entering in item 24d of Form CMS-1500 HCPCS code Q5 modifier (service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area) after the procedure code.
Both Locum Tenens and Reciprocal:
A patient’s regular physician or physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services of a substitute physician or physical therapist, if:
- The regular physician or physical therapist is unavailable to provide the services.
- The Medicare beneficiary has arranged or seeks to receive the services from the regular physician or physical therapist.
- The substitute physician or physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days subject to the following exception: A physician or physical therapist called to active duty in the Armed Forces may bill for services furnished under a fee-for-time compensation arrangement for longer than the 60-day limit.
Key Takeaways
The biggest takeaway from learning about Locum Tenens and Reciprocal services is that there are more similarities than differences. Understanding the differences is essential because they can be the difference between correct coding and errors. Understanding what Locum Tenens and Reciprocal mean for physician coverage to continue patient care is imperative to ensure continued care and correct billing, coding, and accountability. The main difference in billing between them is the modifiers Q5 and Q6 to distinguish between the two. Reviewing the Medicare regulations and guidelines and the payer guidelines for further information and clarification is important, especially if changes may occur, and for more detailed information such as covered visit services, continuous period of covered services, and postoperative services.
Best Practices for Coders and Auditors
- Thorough Research: Always review the latest CMS guidelines and payer-specific instructions to stay updated on any changes.
- Accurate Documentation: Ensure that all documentation is completed on the date of service to qualify for billing.
- Proper Use of Modifiers: Distinguish between Locum Tenens and Reciprocal billing by using the correct modifiers (Q5 and Q6).
- Jurisdiction Compliance: Adhere to the specific regulations of the Medicare jurisdiction where the service was provided.
- Continuous Learning: Take opportunities like writing articles to deepen your understanding of complex billing scenarios.
By understanding the nuances of Locum Tenens and Reciprocal billing arrangements, coders and auditors can ensure accurate billing, maintain compliance with Medicare regulations, and support continuous patient care. Stay informed, apply best practices, and leverage available resources to excel in your role.
References
- Cushing, MD, MBA, W. T. (1999). A Physician’s Guide to Locum Tenens. AAFP.
- CMS (Centers for Medicare and Medicaid Services). (October 24, 2024). Medicare Claims Processing Manual. CMS Manual
- CMS (Centers for Medicare and Medicaid Services). (April 4, 2008). CMS Manual System: Pub 100-04 Medicare Claims Processing. CMS Transmittal
- Noridian Medicare. (April 2, 2024). Fee-for-Time Compensation Arrangements and Reciprocal Billing. Noridian
- Palmetto GBA Medicare. (December 2, 2024). Fee-For-Service Time Compensation (Previously Known as Locum Tenens). Palmetto GBA
- CGS Medicare. (2013). Physician Payment Under Locum Tenens Arrangements. CGS Medicare PDF
- Novitas Solutions Medicare. (February 28, 2024). Reciprocal Billing and Fee-for-Time Compensation Arrangements (Formerly Locum Tenens Arrangements). Novitas Solutions
About the Author:
Natasha Timberlake, BSHCM, CRCR, CPC, COC, CPMA, CHONC, CPC-I, CEMA
Natasha has over 15 years of experience with Revenue Cycle Management, including positions in the front office, medical assisting, billing, coding, auditing, and accounts receivable. She has a bachelor’s degree in Healthcare Management from WGU and is pursuing her master’s in Health Information Management at SNHU.