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Update on Assistant Billing for Services Under TRICARE

April 09, 2020
Reimbursement By Kay Hashagen, Senior Consultant

TRICARE is the health care program for uniformed service members, retirees, and their families around the world. Historically, TRICARE has not permitted reimbursement for services provided by physical therapy assistants (PTAs) or occupational therapy assistants (OTAs). The National Defense Authorization Act of 2017, signed on December 12, 2017, includes a provision to add PTAs and OTAs as authorized providers for TRICARE, under the supervision of a physical or occupational therapist. This Act has been accepted, and the Final Rule has finally been published. The Final Rule, outlining the provisions for TRICARE, can be found in the Code of Federal Regulations (CFR) Vol. 85, No. 52, Tuesday, March 17, 2020 Rules and Regulations.


 

Assistant billing for services under TRICARE


Services provided by PTAs will be reimbursed when supervised by a licensed registered physical therapist for TRICARE; Services provided by OTAs will be reimbursed when supervised by a licensed registered occupational therapist for TRICARE. This rule aligns TRICARE with Medicare’s supervision and qualification rules and is effective 30 days from the March 17, 2020 CFR posting. The updated rule is effective on April 16, 2020.

TRICARE is required to follow Medicare guidelines and reimbursement based upon Title 10 United States Code (U.S.C.), Chapter 55, §1079(h)(1). This means, care must be provided within the scope of the license and prescribed and monitored by a physician, certified physician assistant, or certified nurse practitioner. Adding coverage services by authorized therapy assistants comes at a critical time as the Agency anticipates an increase in their active and aging beneficiary population.

Summary of the Major Provisions of the Final Rule

Major provisions of the Final Rule include the addition of licensed or certified PTAs as TRICARE-authorized providers, operating under the same qualifications established by Medicare (42 Code of Federal Regulations (CFR) 484.115 or successor regulation). These services must be furnished under the supervision of a TRICARE-authorized licensed registered physical therapist.

Also included is the addition of licensed or certified OTAs as TRICARE-authorized providers, operating under the same qualifications established by Medicare (42 CFR 484.115 or successor regulation). These services must be furnished under the supervision of a TRICARE-authorized licensed registered occupational therapist.

Direct supervision will be required in a private practice setting where the supervising physical or occupational therapist will be required to be in the office suite where the PTA or OTA is located and immediately available to furnish assistance and direction throughout the performance of the procedure. General supervision will be required in all settings other than private practice. General supervision will require that procedures be performed by the PTA or OTA, under the physical or occupational therapist’s overall direction and control, but the therapist’s presence will not be required during the performance of the procedure. In cases where state or local supervision laws are more stringent, the Defense Health Agency will require therapists and the assistants they supervise to follow state or local laws.

One area not mentioned in the Final Rule is whether or not TRICARE will implement the payment reduction for services provided by assistants when the CO and CQ Modifiers are reported. Stay tuned on this one.

Need help with therapy documentation, coding and billing best practices? Contact the experts at LW Consulting, Inc. today!

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