(Medicare Claims Processing Manual)

A continuous period of covered visit services begins with the first day on which the substitute physician or physical therapist provides covered visit services to Medicare Part B patients of the regular physician or physical therapist, and ends with the last day the substitute physician or physical therapist provides services to such patients before the regular physician or physical therapist returns to work.  This period continu es without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or physical therapist or are furnished by some other substitute physician or physical therapist on behalf of the regular physicia n or physical therapist.    A new period of covered visit services can begin after the regular physician or physical therapist has returned to work.    EXAMPLE:  The regular physician or physical therapist goes on vacation on June 30, and returns to work on September 4.  A substitute physician or physical therapist provides services to Medicare Part B patients of the regular physician or physical therapist on July 2, and at various times thereafter, including August 30 and September 2.  The continuous period of covered visit services begins on July 2 and runs through September 2, a period of 63 days.  Since the September 2 services are furnished after the expiration of 60 days of the period, the regular physician or physical therapist is not entitled to bill and receive direct payment for the services furnished August 31 through September 2.  The substitute physician or physical therapist must either bill f or the services furnished August 31 through September 2 in his/her own name and billing number or reassign payment to the person or group that bills for the services of the substitute physician or physical therapist.  The regular physician or physical ther apist may, however, bill and receive payment for the services that the substitute physician or physical therapist provides on behalf of the regular physician or physical therapist in the period July 2 through August 30.  The requirements for the submission of claims under reciprocal billing arrangements are the same for assigned and unassigned claims.  A/B MACs Part B should inform physicians and physical therapists of the compliance requirements when billing for services of a substitute physician or physical therapist. The physician or physical therapist notification should state that, in entering the Q 5 modifier, the regular physician or physical therapist (or the medical group or physical therapy group, where applicable) is certifying that the services are covered visit services furnished by the substitute physician or physical therapist identified in a record of the regular physician or physical therapist which is available for inspection, and are services for which the regular physician or physical therapist (or group) is entitled to submit the claim.  A/B MACs Part B should include in the notice that  penalty for false certifications may include civil or criminal penalties for fraud, or administrative penalties including revocation of the physicians or physical therapists Medicare billing privileges, right to receive payment, or to submit claims or a ccept any assignments.  The revocation procedures are set forth under 42 CFR 424.535 and in the Medicare Program Integrity Manual (Pub. 100- 8).  If a line item includes the code Q5 certification, A/B MACs Part B assume that the claim meets the requirements of this section in the absence of evidence to the contrary.  A/B MACs Part B need not track the 60- day period or validate the billing arrangement on a prepayment basis, absent postpayment findings that indicate that the Q5 certifications by a particular regular physician or physical therapist may not be valid.  When A/B MACs Part B make Part B payment under this section, they determine the payment amount as though the regular physician or physical therapist provided the services.  The identification of the substitute physician or physical therapist is primarily for purposes of providing documentation to verify upon audit that the services were actually furnished, not for purposes of the payment or the limiting charge.  Also, notices of noncoverage are to be given in the name of the regular physician or physical therapist.   B.  Requirements applicable to Physician Medical Group or Physical Therapy Group Claims Under Reciprocal Billing Arrangements   In order for a medical group or physical therapy group to submit claims in the name of the regular physician or physical therapist for the services of a substitute physician or physical therapist, the substitute physician or physical therapist may not have reassigned his or her right to Medicare payment to the group through a CMS -855R reassignment enrollment form approved by the A/B MACs Part B and the following requirements must be met:    The regular physician or physical therapist is unavailable to provide the services;     The Medicare patient has arranged or seeks to receive the services from the regular physician or physical therapist; and    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 reciprocal billing arrangement for longer than the 60- day limit.   Services are billed for the entity as follows:   The medical group or physical therapy group must enter in item 24d of Form CMS -1500 the HCPCS code modifier Q5 after the procedure code.    The designated attending physician for a hospice patient (receiving services related to a terminal illness) bills the Q5 modifier in item 24 of Form CMS -1500 when another group member covers for the attending physician.   A record of each service provided by the substitute physician or physical therapist must be kept on file along with the substitute physicians or physical therapists NPI.  This record must be made available to the A/B MAC Part B upon request.   In addition, the medical group physician or group physical therapist on whose behalf the services were furnished by a substitute must be identified by his/her NPI in block 24J of the appropriate line item.   On claims submitted by a group, the group physician or group physical therapist who actually performed the service must be identified in the manner described in 30.2.13, with one exception.  When a group member provides services on behalf of another group member who is the designated attending physician for a hospice patient, the Q5 modifier may be used by the designated attending physician to bill for services related to a hospice patients terminal illness that were performed by another group member.   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  (Rev.  3774, 05- 12-17, Effective:06- 13-17, Implementation: 06- 13-17)  A.  Background   It is a longstanding practice for a physician to retain a substitute physician to take over his/her professional practice when the physician is absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for such physician (the regular physician) to bill and receive payment for the substitute physicians services as though he/she performed them.  The substitute physician often has no practi ce of his/her own and may move from area to area as needed.  The regular physician generally pays the substitute physician on a per diem or other fee -for-time compensation basis with the substitute physician having the status of an independent contractor, rather than of an employee, of the regular physician.  A regular physician or physical therapist is the physician or physical therapist who is normally scheduled to see a patient.  A regular physician may include a physician specialist (such as a cardiologist, oncologist, urologist, hospitalist, etc.).  Under section 16006 of the 21st Century Cures Act, a Medicare- enrolled physical therapist may use a substitute physical therapist to furnish outpatient physical therapy services in a HPSA, a MUA, or a rural area under a fee -for-time compensation arrangement on or after June 13, 2017.  B.  General requirements applicable to all Fee- For-Time Compensation Arrangements    A patients 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 regular physician or physical therapist pays the substitute for his/her services on a per diem or similar fee -for-time basis;    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; and    The regular physician or physical therapist indicates that the services were provided by a substitute physician or physical therapist 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.   If the only services a physician performs in connection with an operation are post-operative services furnished during the period covered by the global fee, these services need not be identified on the claim as services furnished by a substitute physician.  With respect to physicians, the term  covered visit service includes not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as incident to the physicians services.   With respect to physical therapists, the term  covered visit service  means outpatient physical therapy services furnished in a HPSA, a MUA, or a rural area.  HPSAs and MUAs are designated by HRSA.  To determine if an area is a HPSA or an MUA, visit HRSAs website at https://www.hrsa.gov.  A rural area is any area that is outside of a Metropolitan Statistical Area or a Metropolitan Division (in the case where a Metropolitan Statistical Area is divided into Metropolitan Divisions), as defined by the Executive Office of Management and Budget, or the following New England counties: Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island.  To determine if an area is rural, consult the Crosswalk of Counties to Core- Based Statistical Areas in the most current Inpatient Prospective Payment system final rule.  Any area that is not designated as urban in the crosswalk is rural.  A continuous period of covered visit services begins with the first day on which the substitute physician or physical therapist provides covered visit services to Medicare Part B patients of the regular physician or physical therapist, and ends with the last day the substitute physician or physical therapist provides services to such patients before the regular physician or physical therapist returns to work.  This period continues without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or physical therapist or are furnished by some other  substitute physician or physical therapist on behalf of the regular physician or physical therapist.  A new period of covered visit services can begin after the regular physician or physical therapist has returned to work.    EXAMPLE:  The regular physician or physical therapist goes on vacation on June 30, and returns to work on September 4.  A substitute physician or physical therapist provides services to Medicare Part B patients of the regular physician or physical therapist on July 2, and at various times thereafter, including August 30 and September 2.  The continuous period of covered visit services begins on July 2 and runs through September 2, a period of 63 days.  Since the September 2 services are furnished after the expiration of 60 days of the period, the regular physician or physical therapist is not entitled to bill and receive direct payment for the services furnished August 31 through September 2.  The substitute physician or physical therapist must either bill f or the services furnished August 31 through September 2 in his/her own name and billing number or reassign payment to the person or group that bills for the services of the substitute physician or physical therapist.  The regular physician or physical ther apist may, however, bill and receive payment for the services that the substitute physician or physical therapist provides on behalf of the regular physician or physical therapist in the period July 2 through August 30.  The requirements for the submission of claims under fee -for-time compensation arrangements are the same for assigned and unassigned claims.   A/B MACs Part B should inform physicians and physical therapists of the compliance requirements when billing for services of a substitute physician or physical therapist. The physician/physical therapist notification should state that, in entering the Q6 m odifier, the regular physician or physical therapist (or the medical group or physical therapy group, where applicable) is certifying that the services are covered visit services furnished by the substitute physician or physical therapist identified in a r ecord of the regular physician or physical therapist which is available for inspection, and are services for which the regular physician or physical therapist (or group) is entitled to submit the claim.  A/B MACs Part B should include in the notice that pe nalty for false certifications may include civil or criminal penalties for fraud, or administrative penalties including revocation of the physicians or physical therapists Medicare billing privileges, right to receive payment, or to submit claims or acce pt any assignments.  The revocation procedures are set forth under 42 CFR  424.535 and in the Medicare Program Integrity Manual (Pub. 100- 8).