TRICARE has published its new policies regarding payment for PTA/COTA services and related matters.
The PTA policy can be found at : https://manuals.health.mil/pages/DisplayManualHtmlFile/TP15/62/AsOf/TP15/C11S3_16.html
The COTA policy, which is a mirror of the PTA policy, can be found at: https://manuals.health.mil/pages/DisplayManualHtmlFile/TP15/62/AsOf/TP15/C11S3_17.html
The following is a summary of the TRICARE policies:
- PTAs and COTAs must abide by their state practice acts, so no evaluations, diagnoses, establishing plan of care or changing plan of care.
- In private practice settings (practices owned by therapists or physicians), PTAs must be directly supervised by a physical therapist and COTAs must be directly supervised by an occupational therapist. Direct supervision requires the supervising therapist to be in the office suite where the PTA/COTA is located and immediately available to furnish assistance and direction throughout the performance of services. The therapist is not required to be in the room with the PTA/COTA while the services are performed. (This is the same supervision level required by Medicare.)
- In an institutional setting, general supervision is required. General supervision means the services are furnished by the PTA under the physical therapist’s overall direction and control and services are furnished by the COTA under the occupational therapist’s overall direction and control; however, the respective therapist’s presence is not required during the performance of the services.
- Home health agencies must comply with the general supervision requirement and the therapist must provide the ordered therapy service at least once every 30 days to functionally reassess the patient and compare new measurements to previous measurements. Home health agencies are also responsible for ensuring services are provided in accordance with Medicare Benefits Policy Manual, Chapter 7, “Home Health Services” for maintaining medical records and ensuring all records are documented as required by the Medicare Conditions of Participation at 42 CFR 484.110. If there is a conflict between this TRICARE policy and Medicare’s requirements for home health agencies, Medicare’s requirements take precedence.
- Claims for outpatient PTA/COTA services are submitted under the supervising therapist’s NPI.
- As with Medicare outpatient PT/OT claims, claims for PTA services must include the CQ modifier and claims for COTA services must include the CO modifier. Starting in 2022, PTA/COTA payment rates will be 85% of the rates paid for therapist services.
- PTA/COTA services cannot be billed incident to a physician, PA or NP. PTA claims can only be billed under a physical therapist and COTA claims can only be billed under an occupational therapist.
- Services performed by a student are not covered.
- Aide services are not covered.
- TRICARE will pay for PTA/COTA services according to these rules for dates of service on and after April 16, 2020.