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Tricare and Private Practice PTAs

March 18, 2014 14 Comments

thunderbird flybyTricare policy does not allow for therapy to be paid when it is provided by a physical therapist assistant (PTA) in private practice settings.  A previous post on this generated a lot of comments , as well as a lot of email.  The reference in that post on Tricare and private practice PTAs was the provider manual for the Tricare North Region.  (Do you know which region you are in?).  The 2014 Tricare Provider Manual for the North Region has recently been published online, and continues to state as part of its exclusions list (page 70):  “physical therapy services performed by a physical therapy assistant”.

As a result of my previous post many providers called the other Tricare regions (South and West) to find out that the provider manual for those regions did not specifically mention exclusions related to therapy provided by physical therapists assistants (PTAs).  Another provider contacted me to indicate that she uses the underlying federal regulations as a guideline, even through the prohibition against PTAs is not in her region’s manual.

Tricare and Private Practice PTA – Policy in the Code of Federal Regulations

To clarify, the exclusion of PTAs as providers, is limited to PTAs in private practice, as noted in the policy below based upon the Code of Federal Regulations at 32 CFR 199. 6(c)(2).  So those providers utilizing PTAs (under appropriate supervision) in hospitals and other institutional providers such as Rehab Agencies and CORFs are not subject to the PTA exclusion.  The Tricare Policy, is noted below.

 Services Rendered By Employees Of Authorized Independent Professional Providers

Issue Date: April 19, 1983,   Authority:32 CFR 199.6(c)(2)

1.0 DESCRIPTION

Services commonly furnished by employees in physicians’ offices or clinics which are either rendered without charge or included in the physicians’ bills are referred to as services furnished incident to a physician’s professional services. This means that the services are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.

2.0 POLICY

Services rendered by employees (i.e., aides, technicians, attendants, etc.) of an authorized independent individual professional provider (hereafter referred to as an authorized provider) are subject to the following criteria:

2.1 The individual must be an employee for whom the authorized provider, as employer, pays a salary, Social Security taxes, Workmen’s Compensation, etc.

2.2 The services must be performed under the authorized provider’s direct personal supervision.

2.3 The authorized provider must bill for the services rendered by the employees.

2.4 The services rendered must be otherwise covered, and not of a type usually performed only by a physician or other authorized provider.

3.0 EXCLUSION

Services performed by a physical therapy assistant who is employed by an independent provider, may not be cost-shared.

Do you provide services under Tricare (a Federal health care program)?  Do you use physical therapist assistants?  Do you have a facility policy in your private practice setting for therapy services provided to Tricare enrollees?  Have staff been trained on this policy?

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (14)

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  1. Dan Martin says:

    Nancy,

    I have reviewed 32 CFR 199.6(c)(2) and find:

    (c)(2)Conditions of Authorization
    (i)Professional licensure requirements
    (ii)Professional Certification requirements
    (iii) Education, training,and experience requirements
    (iv) Physician Referral and Supervision

    I cannot locate the language you sited above related to the Description/Policy and Exclusions for PTA’s. Can you offer additional guidance for that specific language?

  2. Dan – Thank you for your comments. The CFR reference noted above is the underlying authority to the Tricare Policy Manual Chapter 11, Section 10.1. (April 19, 1983). Section III of this policy notes; “Services performed by a physical therapy assistant who is employed by an independent provider, may not be cost-shared.”

  3. Dan Martin says:

    Thanks Nancy, I found it. Can you offer just a little more clarification that this exclusion would not apply to home health agencies or SNF’s as they are institutional providers? Would it be a good rule of thumb that if you bill on a 1500 form that PTA’s are excluded from coverage and that if you bill on a UB you are not excluded? Your assistance is greatly appreciated!

  4. Providers that have enrolled with Tricare as individual practitioners are subject to the assistant exclusion from payment, or what Tricare calls “cost sharing”. Institutional providers do not appear to be subject to this exclusion, because it is the institution that is enrolled, not the individual provider. Thanks again for taking the time to comment.

  5. Megan says:

    We are an outpatient hand therapy clinic that utilizes both PT’s and OT’s. Does the apply to Occupational Therapy Assistants as well?
    Thanks!

  6. Michelle says:

    We are a physician owned clinic that provided physical and occupational therapy, we bill under the physician, can a PTA treat and bill a Tricare patient?

  7. Hi Michelle, and thank you for your question. In the Tricare program a PTA cannot bill when working for a physician practice or a therapy private practice. Since you are billing “incident to” the physician, it is the physician that bills for the service that he/she directly supervised. As noted in quote above “3.0 EXCLUSION: Services performed by a physical therapy assistant who is employed by an independent provider, may not be cost-shared.”

    As an aside, PTAs working in physician practices where billing is incident to the physician, may not provide therapy services to Medicare beneficiaries. If you would like to further discuss billing federal healthcare programs for the services of a PTA, or the broader topic of billing incident-to the physician please feel free to schedule a call” http://clarity.fm/nancybeckley.

  8. ginger says:

    Can a rehab technician/aide provide exercise instruction to a Tricare patient under the direct supervision of a licensed physical therapist?

  9. Thank your for your comment. Tricare is a federal healthcare program, and to that end physical therapy should be provided by qualified therapists. For Medicare that is either a physical therapist or a physical therapist assistant. Tricare has provided additional policy guidance that in private practice physical therapy must be provided by the physical therapist (professional settings). Tricare does not limit the provision for PTAs in institutional providers (hospitals, skilled facilities, rehab agencies etc). An aide would not be considered a qualified therapist for the purpose of rendering physical therapy in a federal healthcare program.

  10. Hidee says:

    Just a question. If a pta is working at a hospital based outpatient facility can they treat tri care patients ?

  11. Thank you for your question. The cost-sharing prohibition for PTAs is applicable only to professional services (private practice), and does not apply to institutional setting, in which the “setting” rather than the individual practitioner is enrolled.

  12. Christiana says:

    Nancy, can you tell my if these guidelines hold true for COTAs in a private outpatient practice as well?
    Thank you

  13. Christina – Thank you for your comment. The Tricare policy manual (not the Provider Handbook) specifies that the services of a physical therapist assistant (PTA) many not be cost shared. As a best practice I would consider that the focus is on “assistants” rather than a just specifically PTAs.

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