The term locum tenens comes from Latin, meaning “to hold the place of.” In healthcare, it refers to temporary healthcare providers who fill the role of a regular provider who is unavailable for a short period.
For Medicare beneficiaries, the locum tenens program offers a crucial solution. It allows a Medicare-enrolled regular Physical Therapist (PT) to use a substitute PT to provide treatment when the regular PT is temporarily unavailable under section 16006 of the 21st Century Cures Act. This means that patients can continue to receive the care they need, even when their primary PT is away. The temporary or substitute PT can treat patients for a specific period (up to 60 days) while the primary or regular PT is unavailable.
While the locum tenens program has been available for PTs in rural and medically underserved areas since June 13, 2017, it’s important to note that the rules around this program are different for all healthcare providers. Unlike physicians in various specialties who can use locum tenens nationwide, PTs face restrictions that limit this option based on geography. To determine whether your practice in a region is considered a Medically Underserved Area (MUA)/rural area or a Health Professional Shortage Area (HPSA), visit the HRSA’s website.
Who Does Locum Tenens Not Apply To?
- The “locum tenens” policy does not extend to Occupational Therapists (OTs) or Speech-Language Pathologists (SLPs) in private practice. Neither the American Occupational Therapy Association nor the American Speech-Language-Hearing Association have been involved in lobbying efforts for changes in future legislation.
- This rule is only for private practice PTs who bill Medicare directly using the CMS 1500 form. Hospitals, skilled nursing facilities (SNFs), and other institutional settings have their processes for hiring temporary staff, which are unaffected by this rule.
- It’s important to note that Physical Therapist Assistants (PTAs) are not included in the locum tenens arrangement. However, if the practice needs a temporary PTA, you can still bring one on board, as long as they work under the direct supervision of a licensed PT billing Medicare. This ensures patient care continues, even when the regular PT is temporarily unavailable.
Key Details
- Substitute PTs Can Be Hired Temporarily: The locum tenens program provides PTs the flexibility they need. Another licensed PT may provide treatment to Medicare patients while the regular PT is away due to illness, vacation, or attending continuing education.
- Bill Medicare for Services: In Medicare billing, to ensure patient care continuity, the regular PT may be substituted by another PT to provide outpatient therapy services when the regular PT is temporarily unavailable. The Medicare Claims Processing Manual, Chapter 1, Sections 30.2.1; 30.2.10, 30.2.11, 30.2.13, and 30.2.14 explains the difference between Reciprocal Billing and Fee-for-Time Compensation Arrangements.
- Reciprocal Billing: A regular PT can submit claims and receive Part B payment for covered services provided by a substitute PT during short absences, like vacations or emergencies. They can have arrangements with multiple PTs and do not need to be in writing.
- Duration: The substitute PT can provide services for up to 60 continuous days.Billing: Claims are submitted under the regular PT’s NPI. Use modifier Q5 to indicate substitute services. For instance, PT A is on leave. PT B substitutes for 45 days. The claim has PT A’s NPI, and the Q5 modifier is used.Group Practices: A PT group can submit claims to Medicare under the regular PT’s name for services provided by a substitute PT. However, the substitute PT must not give up their right to receive Medicare payments to the group. The PT group must enter the modifier Q5 after the procedure code.Documentation: Maintain records of each service the covering PT provides, including the substitute PT’s NPI. Records must be available upon request.
- Fee-for-Time Compensation Arrangements – Regular PT is unavailable, and substitute PT is paid per diem or similar fee-for-time.
- Duration: The substitute PT can provide services for up to 60 days unless the regular PT is called to active military duty.
- Billing: Claims are submitted under the regular PT’s NPI. Use modifier Q6 to indicate substitute services. For example, PT A hires PT B for 30 days to cover leave. PT A bills using modifier Q6 for PT B’s services.
- Group Practices: Groups can bill for substitutes if the substitute has not reassigned their Medicare billing rights to the group. Q6 is entered in the CMS-1500 Form or electronically for billing substitute services. For example, a rural PT group hires PT C to temporarily replace PT D. The group submits claims under PT D’s NPI with modifier Q6.
- Documentation: Keep records of the services the substitute provided, including their NPI number. Records must be available upon request.
- Reciprocal Billing: A regular PT can submit claims and receive Part B payment for covered services provided by a substitute PT during short absences, like vacations or emergencies. They can have arrangements with multiple PTs and do not need to be in writing.
- Modifiers and Claims: Always use the GP modifier to indicate that a physical therapist (PT) provided the service, as it helps CMS identify the provider and process your claim accurately. Other modifiers include the KX modifier for therapy services over the cap and the -59 modifier for unbundling code pairs, which also aid CMS in processing claims correctly.
- Active Duty Military Exception: If a PT is called to active duty as a member of a reserve component of the Armed Forces for more than 60 days, the Centers for Medicare & Medicaid Services (CMS) will allow payment for services provided by a substitute PT under the fee-for-time compensation arrangements throughout that period.
Importance of Locum Tenens Program for Physical Therapists
- Continuity of Care: It is really important for patients, especially those on Medicare, to keep getting care even when their regular therapist is temporarily out. When there’s a break in treatment, it can affect the patient’s quality of care.
- Revenue Flow: Small practices, especially those in rural areas, can experience revenue issues if a therapist is unable to see patients. Hiring a locum tenens provider allows the practice to generate revenue during the therapist’s absence. This is particularly important for solo practitioners or small clinics that rely on a steady flow of patient visits to cover overhead costs.
- Work-Life Balance for PTs: PTs also need time for personal reasons. Whether it’s taking a vacation or handling a personal matter, the ability to hire a substitute therapist allows providers to take care of themselves while ensuring their patients are well cared for.
Example of Locum Tenens
For instance, a small outpatient PT clinic in a rural town is the only PT provider in the area. The lead PT, who runs the clinic, is scheduled to attend a week-long conference on continuing education. Without the ability to hire a locum tenens therapist, the clinic would need to either cancel patient appointments or refer patients to distant clinics, disrupting patient care and affecting the clinic’s bottom line. Similarly, if the lead PT is on a planned vacation or is unexpectedly ill, the locum tenens program is an option for the clinic and its patients.
Due to the locum tenens program, this clinic can bring in a qualified substitute PT for the week. This ensures patients continue to receive care without delay and significantly relieves the lead therapist, who can attend the conference without stressing about patient care or financial loss.
How to Avoid Violations
- Understand and Follow Medicare Guidelines
- Familiarize yourself with Medicare’s rules for locum tenens, including the continuous 60-day rule.
- The 60-day count would continue on the first day the substitute PT sees a patient, not when the regular PT takes their absence; it ends with the last day the substitute PT provides patient services before the regular PT returns to work.
- If the regular PT returns to work and must leave again, the same substitute PT is hired; a new 60-day period begins.
- Familiarize yourself with Medicare’s rules for locum tenens, including the continuous 60-day rule.
- Verify Licenses and Credentials
- Use online resources like your state’s professional licensing board to verify the therapist’s credentials.
- Document Everything
- Maintain precise records of employment contracts, schedules, and the locum tenen’s qualifications.
- Use Correct Billing Codes
- Ensure billing staff are trained to use appropriate modifiers for locum tenens claims (e.g., modifier Q6 for Medicare).
- Audit Regularly
- Conduct periodic audits to ensure compliance with all locum tenen regulations.
If a PT outpatient clinic is not eligible for coverage under CMS locum tenens guidelines, there are still options to handle staffing needs. Check for exceptions—some areas, like Health Professional Shortage Areas (HPSA) or Medically Underserved Areas (MUA), may have more flexible locum tenens rules. Contact Your Medicare Administrative Contractor (MAC). The MAC is your go-to source for information and provides region-specific details about billing and required documents.
Locum tenens arrangements are crucial for outpatient therapy clinics. They ensure smooth operations while adhering to regulatory standards. Clinics can maintain continuity of patient care by understanding compliance and implementing best practices.
This program is essential for PTs in rural or underserved areas, as it supports Medicare patient care and demonstrates the PTs’ commitment to their patients during personal or professional challenges.
Additionally, locum tenens allows PTs to take leave without disrupting clinic operations, ensuring consistent patient care. This flexibility helps PTs maintain a healthy work-life balance and enhances their well-being.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!