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Reciprocal billing and fee-for-time compensation arrangements (formerly locum tenens arrangements)
Last Modified: 2/22/2024
Location: FL, PR, USVI
Business: Part A, Part B
The requirements for the submission of claims under reciprocal billing and fee-for-time compensation arrangements are the same for assigned and non-assigned claims.
For the purposes of this article, the CMS definition of "physician" includes doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery or dental medicine, doctor of podiatric medicine or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic.
Under section 16006 of the 21st Century Cures Act, a Medicare-enrolled physical therapist may use a substitute physical therapist to offer outpatient physical therapy services in a health professional shortage area (HPSA), a medically underserved area (MUA), or a rural area under a reciprocal billing arrangement on or after June 13, 2017.
A patient's regular physician or physical therapist may submit claims, and if assignment is accepted, may receive Part B payment for covered services (including emergency visits and related services) the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:
• The regular physician or physical therapist is unavailable to supply the services.
• The Medicare patient arranges or seeks services from the regular physician or physical therapist.
• The services must not be provided by the second physician over a continuous period of more than 60 days unless the regular physician is called or ordered to active duty as a member of a reserve component of the Armed Forces.
• The regular physician or physical therapist identifies the services as substitute physician services by reporting modifier Q5 (service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a HPSA, MUA, or a rural area) with the procedure code.
The regular physician or physical therapist must keep on file a record of each service provided by the substitute physician or physical therapist along with the substitute physician or physical therapist's National Provider identifier (NPI). The record must be available upon request.
If the only services a physician performs in connection with an operation are post-operative services given during the period covered by the global fee, these services need not be identified on the claim as services furnished by a substitute physician.
A physician or physical therapist may have reciprocal billing arrangements with more than one physician or physical therapist. The arrangements do not need to be in writing.
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 and the above listed requirements must be met.
Q5 modifier
The medical group or physical therapy group must enter the HCPCS code modifier Q5 after the procedure code in item 24d of Form CMS-1500 or electronically in loop 2400 Segment SV101-3.
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 or electronically in loop 2400 Segment SV101-3 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 physician's or physical therapist's 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 or her NPI in block 24J of the proper line item or electronically in loop 2420A Segment NM109.
Under section 16006 of the 21st Century Cures Act, a Medicare-enrolled physical therapist may use a substitute physical therapist to give 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.
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 supply the services.
• The Medicare beneficiary has arranged or looks to receive the services from the regular physician or physical therapist.
• The regular physician or physical therapist pays the substitute for his or her services on a per diem or similar fee-for-time basis.
• The services must not be provided by the second physician over a continuous period of more than 60 days unless the regular physician is called or ordered to active duty as a member of a reserve component of the Armed Forces.
• The regular physician or physical therapist indicates 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 shown on the claim as services furnished by a substitute physician.
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 and the above listed requirements must be met.
For purposes of these requirements, per diem or similar fee-for-time compensation which the group pays the substitute is considered paid by the regular physician or physical therapist. Also, a physician or physical therapist who has left the group and for whom the group has engaged a substitute as a temporary replacement may bill for the temporary physician or physical therapist for up to 60 days. The term "regular physician or physical therapist" includes a physician or physical therapist who has left the group and for whom the group has hired the substitute as a replacement.
Q6 modifier
The medical group or physical therapy group must enter in item 24d of Form CMS-1500 or electronically in loop 2400 Segment SV101-3, the HCPCS code modifier Q6 after the procedure code.
The designated attending physician for a hospice patient (receiving services related to a terminal illness) bills the Q6 modifier in item 24 of Form CMS-1500 or electronically in loop 2400 Segment SV101-3 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 physician's or physical therapist's NPI. This record must be made available to the A/B MACs Part B upon request.
In addition, the medical group physician or group physical therapist on whose behalf the services were given by a substitute must be identified by his or her NPI in block 24J of the proper line item or electronically in loop 2420A Segment NM109.
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 given by the substitute physician or by others as "incident to" the physician's services.
With respect to physical therapists, the term "covered visit service" means outpatient physical therapy services given in a HPSA, a MUA, or a rural area. HPSAs and MUAs are named by the Health Resources & Services Administration (HRSA). To find if an area is a HPSA or an MUA, visit the
HRSA 
website.
A rural area is any area outside of a Metropolitan Statistical Area or a Metropolitan Division. 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 not named 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 another 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 supplies 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 end 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 for the services furnished August 31 through September 2 in his or 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 therapist may, however, bill and receive payment for the services 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 limiting charge and payment for reciprocal or fee-for-time services will be calculated as though the regular physician or physical therapist supplied the services.
Advanced beneficiary notices for not medically necessary services are issued in the name of the regular physician or physical therapist.
A physician, physical therapist or other person, who falsely certifies the requirements for reciprocal and fee-for-time billing arrangements are met, may be subject to civil and criminal penalties for fraud. The physician's or physical therapist's right to receive payment, or submit claims or accept assignment, may be revoked.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
