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TRICARE Releases Final Rule on Use of Assistants

By Rick Gawenda, PT

TRICARE has finally issued the long-awaited final rule to add physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) as TRICARE authorized providers to provide physical therapy or occupational therapy services under the supervision of a TRICARE-authorized physical therapist (PT) or occupational therapist (OT) in accordance with Medicare’s rules for supervision and qualification.

TRICARE will implement the same supervision requirements for PTAs and OTAs as the Medicare program has for outpatient therapy services. This means TRICARE will require direct supervision of a PTA and OTA in the private practice setting and general supervision of a PTA or OTA in a nonprivate practice setting.

Direct supervision requires the PT or OT to be in the office suite where the PTA or OTA is treating the TRICARE beneficiary and immediately available to furnish assistance and direction throughout the performance of the procedure.

General supervision requires the PT or OT to be available if needed by the PTA or OTA but does not require the PT or OT to be in the office suite or on the premise. If state law requires more stringent supervision requirements than general supervision, then you must adhere and follow your state practice act.

Regarding payment for services provided by a PTA and OTA, TRICARE states the following in the final rule: “TRICARE is required by statute (Title 10 United States Code (U.S.C.) chapter 55, §1079(h)(1)) to reimburse like Medicare, to the extent practicable. PT and OT services will continue to be reimbursed under existing TRICARE reimbursement methodology, including the CHAMPUS Maximum Allowable Charge (CMAC) methodology and applicable diagnosis related groups, except that any Medicare reimbursement requirements specific to services provided by PTAs and OTAs will also be adopted, when practicable.”

This means TRICARE could implement the CQ and CO modifiers and pay for services provided by a PTA or OTA at 85% of what a PT or an OT would be paid for providing the exact same services beginning on January 1, 2022. This will be an issue we will want to monitor over the next 18 months.

The final rule was published in the Federal Register on March 17, 2020 and became effective on April 16, 2020.

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Rick Gawenda

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 info@gawendaseminars.com and on Twitter @gawendaseminars.