American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to bill for services performed when you're away

Medicare lets you bill for patient care performed by others—if you meet certain requirements

From the July/August 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: Can I bill Medicare for services provided to my patients by a physician who is covering for me while I'm away from the office?

A: Although Medicare typically only pays physicians who actually furnish a service, it does make exceptions for "covering physician" arrangements. Medicare will pay you for services provided by a covering physician under the following circumstances:

  • You enter into an arrangement with other physicians to cover each other's practice on an occasional, as-needed basis. This is known as a "reciprocal billing" arrangement.
  • You have an agreement with a substitute physician to cover your practice as an independent contractor when you are away from the practice. This is known as a locum tenens arrangement.

While the rules governing these arrangements (described below) are similar, there are some key differences. A reciprocal billing arrangement is typically an agreement among physicians that one will cover the other's practice when the regular physician is absent. Reciprocal billing arrangements are often informal, and Medicare does not require them to be in writing. No money changes hands, and the regular physician compensates the covering physician by reciprocating in the future under similar circumstances. Physicians can have reciprocal billing arrangements with more than one physician.

Coverage periods are usually brief, although Medicare allows them to last up to 60 days if certain criteria are met. Examples of how physicians can use a reciprocal billing arrangement include physicians who occasionally cover for their colleagues during extended office hours and who cover for colleagues who are on-call on the weekend.

Locum tenens arrangements are different. The substitute physician generally does not maintain a practice and travels from area to area as needed. The regular physician typically pays the substitute physician a fixed per-diem amount, with the substitute physician working as an independent contractor, not an employee.

Reciprocal billing arrangements

Medicare will honor reciprocal billing arrangements only if the following conditions are met:

  • The regular physician is unavailable to provide the services;
  • The beneficiary has arranged or seeks to receive the services from the regular physician;
  • The substitute physician does not provide the services to the beneficiary over a continuous period of longer than 60 days; and
  • The regular physician identifies the services as substitute physician services.

The coverage period goes from the first day that the substitute physician provides Medicare Part B services to the regular physician's patients to the last day on which the substitute physician provides services before the regular physician returns to work.

As an example, suppose you plan to go on vacation from July 28 until Aug. 6 and you have arranged for a substitute physician to see your patients in your absence. You can bill for the services that the substitute physician provides to your patients while you are on vacation since the continuous coverage period of 10 days is well under the 60-day limit.

Note: Reciprocal billing arrangement rules do not apply to substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group.

As a result, physicians in medical practices that bill as groups do not need to maintain reciprocal billing arrangements with other members of their group.

Locum tenens arrangements

Medicare recognizes that physicians often retain a substitute physician to take over their professional practices while they are absent for reasons such as illness, vacation, continuing medical education and pregnancy. Medicare further recognizes locum tenens arrangements and pays the regular physician for services provided by the substitute physician if:

  • The regular physician is unavailable to provide the services;
  • The beneficiary has arranged or seeks to receive the services from the regular physician;
  • The regular physician pays the locum tenens physician on a per diem or a fee-for-service basis;
  • The locum tenens physician does not provide services to beneficiaries over a continuous period of longer than 60 days; and
  • The regular physician identifies the locum tenens physician on claims submitted for the services provided by the locum tenens physician.

Billing under reciprocal billing and locum tenens arrangements

Enter the substituting physician's unique physician identification number (UPIN) in field 23 of the standard claim form, known as the HCFA 1500 form. As the billing physician, you need to list your UPIN in field 33 if you are a solo practitioner. You need to list your UPIN in field 24k if you work in a group practice.

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441 or send an e-mail to bbaker@acponline.org.

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