When and How to Bill Using the Loc*ms Q6 & Q5 Modifier (2024)

02
Apr

Billing, Credentialing, General

As a company focused on solving problems for our clients, it’s quite common for us to receive a question about these essential but often misused modifiers. Compliant billing is the only type of billing but there is a lot of misinformation out there regarding these modifiers which makes mistakes common. As one of the largest enrollment and contracting companies in the country, it’s not uncommon for a client to want to use the loc*ms billing modifier due how long it takes to credential and contract a new provider. While we understand the frustration of the credentialing process, we also want you to make decisions that don’t put your practice in jeopardy of an audit or take-back. Listed below are some essential questions you must answer before deciding to use a q6 or q5 modifier. The first question is what’s asked most often.

Using a loc*ms modifier during the credentialing process may seem like an easy solution but it can be a dangerous game to play. We get this question once or twice a week and the simple answer is No. There are very rare exceptions where this is appropriate and compliant. Over the years, we have received permission and instructions from payers such as Humana and UHC to bill under another physician using a loc*ms modifier during the credentialing & contracting process. This is only under extraordinary circ*mstances and only works for groups that have physicians already contracted under the plan. If you’re located in a very underserved area or part of a specialty that is underserved in the region, it’s possible that the payer will grant you permission to bill using a loc*ms modifier.

It’s typically only an option once the provider has been credentialed or has been credentialed previously and is going through the contracting process. If you use a loc*ms modifier or attempt to bill incident-to under another physician, you will likely be paid initially but if you’re ever audited, you could face serious repercussions. For this reason, if you do end up billing incident-to or with a loc*ms modifier, we strongly advise you not to do so for any government payers such as Medicare, Medicaid and Tricare. Again, check with your local network manager and explain to them the situation to see if an exception can be made. We have also had success in obtaining and out-of-network authorization for our physician while he/she is still going through credentialing and this could likely be a better option than doing something that could come back to bite you.

1. Is your event an acceptable case for a locum tenen?

This is the first and most critical question when it comes to staying compliant and getting paid. A locum or substitute physician can provide services for a member of your group (or the owner if solo practice) in the following situations:

Primary physician is ill, on vacation, participating in CME, pregnancy, bereavement, etc.
Primary physician has left the practice and will not be returning

Unacceptable Events:

Hired new physician who is not credentialed or enrolled with insurance companies

2. How long can I bill under Locum Tenen physician?

You can bill for a period of 60 continuous days. If your primary physician will be out for longer than 60 days, it is best to hire someone either part time or full time and complete the necessary credentialing process. The continuous period continues whether locum is actually seeing patients or not. It starts the first day he/she provides services and continues until the primary physician returns to provide services.

3. Can locum tenen perform surgery?

Yes. (If the only services rendered by locum physician are provided as post-operative care under a global period, these need not be identified as being provided by a substitute physician.)

4. How do I submit claims for locum tenens physician?

You submit claims the same way you would for your primary physician except you add a Q6 modifier in box 24d after the procedure code. You may need to check with your billing program provider to ensure that this area of 1500 is populating correctly. Inbox 24j, under rendering provider, you need to keep your primary physician listed.

5. Do I keep records from locum tenens physician in the same place?

You can store the records the same way you would for your primary physician but you should keep a list of patients with DOS that were seen by the substitute physician.

6. How should I pay the locum tenen / substitute physician?

You must pay your locum tenen’s physician on a per diem or similar fee-for-time basis (Hourly). You cannot pay a locum a salary or have a revenue-based payment model (i.e. productivity incentive). Anything other than a per diem fee is in violation of what constitutes a temporary physician.

7. Exceptions to the 60 Day Rule for Q6:

The primary exception afforded to medical groups and the 60 day rule is for active duty military. If you have a provider that is called away to serve, the 60 day rule is waived. It’s important to check with your local Medicare administrator and ensure they do not have any specific requirements but should you encounter this situation, utilizing the q6 modifier for longer than 60 days is acceptable.

8. When to bill using the Q5 modifier for reciprocal billing?

This is used for reciprocal billing under the same EIN. It is used when a physician covers for another physician within the same group. Modifier Q5 is entered after the procedure code in 24d. Both providers must be enrolled in Medicare. Here is an example of when this would be used:

“Dr. Smith provides coverage for Dr. James while Dr. James is out of the office for whatever reason (illness, vacation, etc.). The covering physician, Dr. Smith, must be a permanent part of the existing practice and Tax Identification number. He may not be hired from the outside, operate under a different tax ID number, or bill for services provided under a ‘group practice’ tax ID number.”

We hope that you found this information helpful as you consider when to bill using the Q6 Locum modifier and Q5 Reciprocal Billing modifier. Please contact us if you have any questions.

References:

Outpatient Physical Therapy q6 Modifier

Outpatient Physical Therapy (OPT) have some unique rules as it relates to reciprocal billing arrangements and Fee-For-Time Compensation. We found some great resources and included them below. Please take some time if you are a therapist or employ therapists to familiarize yourself with these rules.

Free Practice Start-up Checklist

Check off the boxes and follow our timeline to ensure nothing is missed or done in the wrong order. This is completely free to any new practice. We do require validation due to competitors that can’t find enough integrity to create their own resources.

1. Established Group- New Provider Credentialing Checklist

Download Checklist New Provider CHecklist

Scenario 1: Utilized if credentialing a new medical provider under an established group

2. Credentialing Checklist- New Practice

Download New practice Credentialing Checklist

Scenario 2: This checklist should be used if you are opening a new medical practice.

FAQs

When and How to Bill Using the Loc*ms Q6 & Q5 Modifier? ›

Modifier -Q5 should be appended for reciprocal billing arrangements when the locum tenens physician has a practice of their own (ie, substitute physician). Modifier -Q6 should be appended for fee-for-time compensation such as when the locum tenens physician has no practice of their own.

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What is the difference between a Q5 and Q6 modifier? ›

Use Q5 when there is a reciprocal billing arrangement and use Q6 when there is a fee-for-time compensation arrangement. Medicare has some specific rules about the time involved so be aware of individual payer policies and their time requirements.

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When should the Q6 modifier be used? ›

The Q6 modifier is a procedure code modifier used on medical claims for the billing of services for a locum tenens physician. It is intended to be used when a physician is away for an extended period of time and arranges for a locum tenens or substitute physician to provide services to their patients in their place.

Does modifier Q6 affect reimbursem*nt? ›

The Q6 modifier is attached to medical claims to signify this substitution, ensuring that the billing process acknowledges the temporary change in healthcare service provider without affecting the continuity of care or the reimbursem*nt process.

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When can a temporary physician be billed using the locum tenens modifier? ›

C.

Also, a physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may bill for the temporary physician for up to 60 days. The group must enter in item 24d of Form CMS-1500 the HCPCS modifier Q6 after the procedure code.

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What is the locum tenens rule? ›

Locum tenens is the practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the substitute ...

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What is an example of a Q5 modifier? ›

You use modifier Q5, for example, when your physician arranges with another doctor to cover each other's patients on weekends. In this situation, Doctor A will see Doctor B's patients and then Doctor B will bill under his NPI using modifier Q5.

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How do you bill under locum tenens? ›

You must also use modifier Q6 (“services furnished by a locum tenens physician”) in box 24D of the CMS-1500 form for each line item service on the claim to indicate the service was provided by a locum. You can bill for services that were provided by a hospital outpatient- based clinic using the UB-04 type of bill.

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Do locum tenens need to be credentialed? ›

The answer is yes. State and federal laws require hospitals to have a process in place to screen all applicants and assess their professional abilities. That's why physicians, physician assistants, and nurse practitioners must undergo a thorough credentialing process prior to taking on a locum tenens assignment.

How do I know which modifier to use? ›

The correct modifier to use is determined by payor preference. There can be instances where a CPT code is further defined by an HCPCS modifier, for example, to describe the side of the body the procedure is performed on, such as left (modifier -LT) or right (modifier -RT).

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Can you bill for a nurse practitioner locum tenens? ›

The CMS billing guidelines for locum tenens physicians do not apply to nurse practitioners and physician assistants. The directions for billing locum tenens NP and PA services differ from state to state. Contact your local Medicare Administrative Contractor to find out if using modifier Q6 is appropriate.

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What is the meaning of locum tenens modifier? ›

Locum tenens is a Latin phrase that means “(one) holding a place.” In the medical field, locum tenens are contracted physicians who substitute for a physician who has left the practice, or who is temporarily unavailable (e.g., on medical leave, on vacation, etc.).

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Which modifier is appended to signify services from locum tenens? ›

CPT/HCPCS codes must have the modifier Q6 appended as this would indicate that the billed services were furnished by the locum or substitute physician.

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What is the Q6 modifier for locum? ›

Q3: When should modifier -Q6 be used in locum tenens billing? A3: Modifier -Q6 should be used when a locum tenens physician does not have a separate practice.

What is the difference between Loc*ms Tenens and per diem? ›

Per diem positions typically offer hourly rates, compensated on a per-shift basis. Meanwhile, locum tenens positions typically offer competitive compensation packages, including a fixed salary or hourly rates, and sometimes additional benefits like housing.

What is a locum tenens and reciprocal billing arrangement? ›

Q5 Definition: Services furnished by a substitute physician under a reciprocal billing arrangement. Locum tenens' are substitute physicians who assume professional practices in the absence of a regular physician for reasons such as illness, pregnancy, vacation, or continuing medical education.

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What is modifier U6? ›

The Effect of Coding Modifier U6 – Non-Contracting Option

be billed to Medicaid by the ancillary services provider. No payment will be made to the DTC for that ancillary service.

How do I bill for a locum tenens physician? ›

You must also use modifier Q6 (“services furnished by a locum tenens physician”) in box 24D of the CMS-1500 form for each line item service on the claim to indicate the service was provided by a locum. You can bill for services that were provided by a hospital outpatient- based clinic using the UB-04 type of bill.

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