By Rick Gawenda*
Q: How many regions are there in the United States that manage the TRICARE program?
A: Currently, there are two regions in the United States: the East Region and the West Region.
Q: Who is the regional contractor for the West Region?
A: Health Net Federal Services is the regional contractor for the West Region. You can access their home page at www.tricare-west.com.
Q: What states are located in the West Region?
A: The following states are located in the West Region: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except the Rock Island Arsenal area), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (Amarillo, Lubbock and El Paso areas only), Utah, Washington, and Wyoming.1
Q: Who is the regional contractor for the East Region?
A: Humana Military is the regional contractor for the East Region. You can access their home page at www.humanamilitary.com.
Q: What states are located in the East Region?
A: The following states are located in the East Region: Alabama, Arkansas, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa (Rock Island area), Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri (St. Louis area), New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas (excluding El Paso area), Vermont, Virginia, West Virginia, and Wisconsin.2
Q: Does TRICARE follow Medicare’s “8-minute rule” when providers are billing for outpatient therapy services?
A: Yes, TRICARE has stated they follow Medicare’s “8-minute rule.” This is based on phone calls with TRICARE. Unfortunately, TRICARE has not published this in their manuals.
Q: Does TRICARE pay for services provided by a physical therapist assistant or occupational therapy assistant under the appropriate supervision of a physical therapist or occupational therapist respectively?
A: Effective April 16, 2020, TRICARE has approved Physical Therapy Assistants (PTA) and Occupational Therapy Assistants (OTA) as TRICARE-authorized providers under the supervision of a TRICARE-authorized, licensed, and registered physical therapist or occupational therapist in accordance with Medicare’s rules for supervision and qualification.3
Q: Has TRICARE implemented the CQ and CO modifiers if services are provided in part or in whole by a PTA or OTA?
A: Yes. TRICARE has implemented the CQ and CO modifiers in the same manner that was implemented by traditional Medicare for outpatient therapy services furnished under Part B benefits.3,4
Q: Will TRICARE reduce the amount of reimbursement when services are provided “in whole” or “in part” by a PTA or OTA?
A: Effective for services rendered on or after January 1, 2022, claims with a modifier of CQ or CO shall be reimbursed at the non-physician class CMAC for the applicable service.4,5
Q: Does TRICARE cover Transcutaneous Electrical Nerve Stimulation?
A: Effective June 1, 2020, TRICARE will no longer cover transcutaneous electrical nerve stimulation (TENS) for the treatment of acute, subacute, and chronic low back pain (LBP).6
Q: Does TRICARE pay for the dry needling CPT codes 20560 and 20561 if performed under a physical therapy plan of care?
A: No. Per TRICARE, dry needling is considered unproven.7
Q: Is TRICARE and CHAMPUS the same?
A: Yes. TRICARE was formerly called CHAMPUS.
Q: Is TRICARE and ChampVA the same?
A: No. Tricare is for active duty military and their dependents. It is a Department of Defense (DOD) benefit. CHAMPVA is a VA benefit for dependents of living veterans rated 100%, for dependents of veterans who died service connected, and for dependents of veterans who were 100% rated when they died.8
Q: How can I access the TRICARE manual?
Scroll down to Navigation and under Navigation on the left-hand side, you will see the word “View.” Under “View” click on Table of Contents at Change. When the new page opens, scroll down and click on TP15 Chap 7 TOC — Medicine. Click on the appropriate section you want to read.
You will also want to click on TP15 Chap 11 TOC — Providers and when the new page opens up, scroll down to Sections 3.16 and 3.17 to read about PTAs and OTAs.
If you have additional questions about TRICARE and outpatient therapy, please feel free to email me at email@example.com.
1Health Net Federal Services. www.tricare-west.com. Accessed July 20, 2020.
2TRICARE Regions. https://www.tricare.mil/About/Regions#. Accessed July 20, 2020.
3Department of Defense. TRICARE; Addition of Physical Therapist Assistants and Occupational Therapy Assistants as TRICARE-Authorized Providers. Federal Register. March 17, 2020;85(52): 32 CFR Part 199. https://www.govinfo.gov/content/pkg/FR-2020-03-17/pdf/2020-04957.pdf
4TRICARE Policy Manual 6010.60-M. Chap 11 TOC – Providers, Section 3.16, 5.0 Reimbursement. https://manuals.health.mil/pages/DisplayManualHtmlFile/TP15/62/AsOf/TP15/c11s3_16.html#FM72932. Published April 2015. Updated April 22, 2020. Accessed July 20, 2020.
5TRICARE Policy Manual 6010.60-M. Chap 11 TOC – Providers, Section 3.17, 5.0 Reimbursement. https://manuals.health.mil/pages/DisplayManualHtmlFile/TP15/62/AsOf/TP15/c11s3_17.html#FM72932 Published April 2015. Updated April 22, 2020. Accessed July 20, 2020.
6TRICARE Policy Manual 6010.60-M. Chap 7 TOC – Medicine, Section 18.2 Physical Medicine/Therapy, 4.17. https://manuals.health.mil/pages/DisplayManualHtmlFile/TP15/62/AsOf/TP15/c7s18_2.html#FM66017. Published April 2015. Updated April 22, 2020. Accessed July 20, 2020.
7TRICARE Policy Manual 6010.60-M. Chap 7 TOC – Medicine, Section 18.2 Physical Medicine/Therapy, 4.18. https://manuals.health.mil/pages/DisplayManualHtmlFile/TP15/62/AsOf/TP15/c7s18_2.html#FM66017. Published April 2015. Updated April 22, 2020. Accessed July 20, 2020
8U.S. Department of Veterans Affairs. Frequently Asked Questions About CHAMPVA. https://www.va.gov/COMMUNITYCARE/programs/dependents/champva/CHAMPVA_faq.asp. Accessed July 20, 2020.
Rick Gawenda, PT, is the founder and president of Gawenda Seminars & Consulting, Inc. and member of the PPS Payment Policy Committee. He may be reached at firstname.lastname@example.org and on Twitter @gawendaseminars.
*The author has a professional affiliation with this subject.