APTA Advisory: TRICARE Manual Updated to Recognize PTAs as Authorized Providers

Don’t forget to use the CQ modifier if more than 10% of a service is furnished by a PTA.

TRICARE, the health insurance system used throughout the military, announced that it has officially revised its policy manual to recognize PTAs (and occupational therapy assistants) as authorized providers, outlining the rules and requirements governing assistant qualifications, scope of practice, supervision, and reimbursement. 

Now it’s up to TRICARE contractors to do the same within approximately 30 days.

As reported earlier, beginning with date of service on April 16, PTAs are recognized as authorized providers under TRICARE and thus eligible for reimbursement for covered services rendered to TRICARE beneficiaries.

Take note: The CQ modifier must be appended to the claim when more than 10% of an outpatient physical therapy service is furnished by the PTA. Check out APTA’s Quick Guide to Using the PTA Modifier.

The presence of the modifier shouldn’t impact claims processing. However, if claims are denied, they may need to be resubmitted if the claims are sent to contractors before they fully implement the change. 

APTA Advocacy Win For CMS Coding Changes

Advocacy efforts by APTA and its members helped CMS and its coding contractor reverse earlier changes that complicated (and sometimes thwarted) a PT’s ability to provide efficient, effective care.

What Happened

Prior to the latest change, reimbursement would be denied if, for example, code 97530 (therapeutic activities) was paired with 97116 (therapeutic procedure) without use of the 59 or applicable X modifier. Those code pairings have been eliminated. Now PTs working in private practice and institutional settings can pair many codes without adding the 59 or applicable X modifier. For a complete list of edit changes go to APTA’s National Correct Coding Initiative webpage .

Which Payers These NCCI Edit Changes Apply to

Medicare and Medicaid programs follow CMS’ NCCI procedure-to-procedure edits. Additionally, most insurers also follow the NCCI PTP edits. APTA encourages providers to use the information in this article and found on the CMS PTP Coding Edits webpage to communicate with commercial payers regarding these edit changes.

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