ModifiedDHAPolicy 6010.60-M

Occupational Therapy Assistant Services

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DHA/TRICARE coverage and administrative requirements for occupational therapy assistant services, including eligibility, supervision, documentation, billing, and exclusions.

Policy Summary

PayerDHA

PolicyOccupational Therapy Assistant Services

Policy CodePolicy 6010.60-M

Change TypeModified — general supervision required for OTPP-supervised OTAs beginning January 1, 2025

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionOTPPs must use general supervision for OTA services beginning January 1, 2025.

SourceLink

POLICY UPDATE CHANGES

For occupational therapists in private practice, direct supervision of OTAs applied through December 31, 2024, and general supervision is required beginning January 1, 2025.

The policy adds January 1, 2025, as the effective date for general supervision of OTAs by occupational therapists in private practice.

Jan 1, 2025OTPP general supervision effective

30 daysHome-health reassessment interval

>10%OTA service share requiring modifier

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ModifiedDHAPolicy 6010.60-M

Occupational Therapy Assistant Services

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Get alerted when Policy 6010.60-M changes without checking for updates manually.

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DHA/TRICARE coverage and administrative requirements for occupational therapy assistant services, including eligibility, supervision, documentation, billing, and exclusions.

Policy Summary

PayerDHA

PolicyOccupational Therapy Assistant Services

Policy CodePolicy 6010.60-M

Change TypeModified — general supervision required for OTPP-supervised OTAs beginning January 1, 2025

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionOTPPs must use general supervision for OTA services beginning January 1, 2025.

SourceLink

POLICY UPDATE CHANGES

For occupational therapists in private practice, direct supervision of OTAs applied through December 31, 2024, and general supervision is required beginning January 1, 2025.

The policy adds January 1, 2025, as the effective date for general supervision of OTAs by occupational therapists in private practice.

Jan 1, 2025OTPP general supervision effective

30 daysHome-health reassessment interval

>10%OTA service share requiring modifier

Required outpatient modifier

4Excluded categories

Coverage Criteria

Basic OTA eligibility and scope

OTA services are eligible for TRICARE coverage when all applicable requirements are met.

Basic OTA eligibility: The OTA meets Medicare qualification requirements under 42 CFR 484.115 or successor regulation; works within state licensure and scope of practice; and is supervised by a licensed registered occupational therapist.

The OTA may not perform an initial examination, evaluation, re-evaluation or assessment, establish a diagnosis, or establish a plan of care.

Provider-specific supervision

Supervision requirements depend on the provider type and must meet the applicable setting-specific requirements.

Provider-specific supervision: For occupational therapists in private practice, general supervision is required beginning January 1, 2025; for institutional providers, general supervision is required; for Home Health Agencies, general supervision plus occupational therapist reassessment at least every 30 days is required; for Comprehensive Outpatient Rehabilitation Facilities, general supervision plus occupational therapist presence on the premises or availability by direct telecommunications during operating hours is required; for rehabilitation agencies, occupational therapist availability and required scheduling and off-premises supervisory visits apply; and for other corporate service providers, applicable Medicare supervision requirements for a substantially similar provider type apply unless less stringent.

State or local requirements control when more stringent than the policy requirements.

Reimbursement and claim requirements

Reimbursement is available when all billing and claim-certification requirements are met.

Reimbursement and billing requirements: Professional OTA services meet applicable supervision requirements; services are billed under the supervising licensed registered occupational therapist's NPI when billed under CMAC; outpatient services furnished in whole or in part by an OTA are reported with modifier CO when the OTA furnishes more than 10% of the service; only one code is submitted for a shared treatment time interval; and the supervising therapist certifies claim accuracy and completion of supporting documentation.Modifier CO applies when OTA involvement exceeds 10% of the service.

Claims with modifier CO for services rendered on or after January 1, 2022, are reimbursed at the non-physician class CMAC for the applicable service.

Services safely and effectively furnished by nonskilled personnel, or by an occupational therapy assistant without supervision from a licensed registered occupational therapist, are excluded from rehabilitative therapy coverage.

Occupational therapy assistant services may not be billed as services incident to or under the supervision of a physician or other allied health professional. Those professionals do not meet the qualifications required of a licensed registered occupational therapist for supervising OTA services.

Services performed by a student are not covered and may not be billed, even when provided under line-of-sight supervision by a licensed registered occupational therapist or OTA. The presence of a student in the room alone does not make an otherwise billable service unbillable.

Services performed by an aide may not be billed, even when the aide is supervised by a licensed registered occupational therapist or OTA.

Coding and Billing Requirements

OTA Billing ModifierModifier

CO	Outpatient occupational therapy services furnished in whole or in part by an OTA when more than 10% of the service is furnished by the OTA.

Referenced Federal Regulationsmixed

42 CFR 484.110	Medicare Conditions of Participation medical-record documentation requirements applicable to Home Health Agencies, or successor regulation.
42 CFR 484.115	Medicare qualification requirements for OTAs, or successor regulation.

OTA service share requiring modifier CO

ModifierModifier CO

ThresholdMore than 10% of total service minutes furnished by the OTA

Applies toOutpatient occupational therapy services furnished in whole or in part by an OTA

Home health occupational therapist reassessment interval

SettingHome health services

Required intervalAt least once every 30 days

Required action

Provider Actions and Denial Risks

Documentation Required

Home Health Records and Certification

Home Health Agencies (HHAs) must provide services in accordance with the Medicare Benefit Policy Manual, Chapter 7, and maintain medical records documented as required by the Medicare Conditions of Participation at 42 CFR 484.110, or successor requirements. The supervising licensed registered occupational therapist certifies that the claim is accurate, supporting documentation is complete, and services were furnished by the therapist or by an OTA under required supervision; if DHA requirements conflict with Medicare HHA requirements, Medicare requirements take precedence.

Maintain complete medical records and required documentation.
Ensure the supervising occupational therapist certifies claim accuracy, supporting documentation, and required OTA supervision.

Denial Risk

HHA 30-Day Reassessment

For HHA services, the licensed registered occupational therapist—not the OTA—must provide the ordered therapy at least once every 30 days to functionally reassess the patient and compare new measurements with prior measurements.

Policy Background

This policy establishes TRICARE coverage for services provided by qualified occupational therapy assistants when they work under the supervision of a licensed registered occupational therapist. OTAs must practice within applicable state licensure and scope-of-practice requirements and may not independently perform examinations, evaluations, assessments, diagnoses, or establish plans of care. Supervision and billing requirements vary by provider setting.

Key Definitions

Direct supervision

Therapist locationThe supervising occupational therapist must be in the office suite where the OTA is located

AvailabilityThe therapist must be immediately available to furnish assistance and direction throughout performance of the services

Same-room presenceThe occupational therapist is not required to be in the room with the OTA while the services are performed

General supervision

Direction and controlThe OTA furnishes services under the occupational therapist's overall direction and control

Therapist presenceThe occupational therapist's presence is not required during performance of the services

Policy Summary

PayerDHA

PolicyOccupational Therapy Assistant Services

Policy CodePolicy 6010.60-M

Change TypeModified — general supervision required for OTPP-supervised OTAs beginning January 1, 2025

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionOTPPs must use general supervision for OTA services beginning January 1, 2025.

SourceLink

On This Page

The licensed registered occupational therapist must provide the ordered therapy service to functionally reassess the patient and compare new measurements with previous measurements

OTA and occupational therapist time billing

Billing ruleOnly one code may be submitted for the same treatment time interval

Applies toServices furnished by both the occupational therapist and OTA during a shared treatment time interval

Claim requirementThe same time interval may not be billed as separate services by both the occupational therapist and OTA

Schedule and document the therapist’s required reassessment at least every 30 days.
Follow more stringent state or local requirements when applicable.

Documentation Required

Rehabilitation Agency Supervision

Rehabilitation agencies must have a licensed registered occupational therapist present or readily available when an OTA furnishes services. If the therapist is not on the premises during all operating hours, schedule patients so the therapist is present when special skills are needed, including evaluation and reevaluation; off-premises OTA services require an on-site supervisory visit by the therapist at least every 30 days, or more often if required by law.

Document therapist availability and scheduling for services requiring special skills.
Complete and document at least one on-site supervisory visit every 30 days for services provided off the organization’s premises.

Denial Risk

OTA Scope-of-Practice Limits

An OTA must work within state licensure and scope-of-practice requirements and may not perform therapist-only functions. Claims are at risk when an OTA performs the initial examination, evaluation, re-evaluation or assessment, establishes a diagnosis, or establishes the plan of care.

Do not assign initial examination, evaluation, re-evaluation, assessment, diagnosis, or plan-of-care functions to an OTA.
Follow more stringent state or local scope-of-practice requirements.

Denial Risk

Required OTA Supervision

OTA services must be furnished under the supervision of a licensed registered occupational therapist, with the number of OTAs reasonable to ensure adequate supervision. Apply the supervision standard for the provider type and the more stringent state or local requirement: OTPPs require general supervision beginning January 1, 2025; institutional providers require general supervision; CORFs require the therapist on premises or available by direct telecommunications; and rehabilitation agencies require therapist presence or ready availability plus applicable supervisory visits.

On or before December 31, 2024, direct supervision applied to OTAs supervised by OTPPs; beginning January 1, 2025, general supervision applies.
Use Medicare supervision requirements for substantially similar provider types when applicable, unless this policy is more stringent.
Do not bill or expect reimbursement when required supervision is absent or not documented.

Billing Rule

Modifier CO and OTA Billing

Outpatient occupational therapy services furnished in whole or in part by an OTA must be reported with modifier CO when the OTA furnishes all service minutes or more than 10% of the total service minutes. Effective for services rendered on or after January 1, 2022, modifier CO claims are reimbursed at the applicable non-physician class CMAC.

Use modifier CO when OTA-furnished minutes exceed 10% of total service minutes, or when the OTA furnishes all minutes.
Bill professional services meeting supervision requirements under the supervising occupational therapist’s NPI.
Submit only one code for a time interval when the therapist and OTA treat during the same interval; do not separately reimburse both.

Denial Risk

Nonskilled or Unsupervised Services

Rehabilitative therapy services are excluded from coverage when they can be safely and effectively furnished by nonskilled personnel or by an OTA without supervision by a licensed registered occupational therapist. OTA services also may not be billed as incident to or under the supervision of a physician or other allied health professional, because those professionals do not meet the required occupational therapist qualifications.

Do not bill services that are safely and effectively furnishable by nonskilled personnel as skilled rehabilitative therapy.
Ensure OTA supervision is provided by a licensed registered occupational therapist, not a physician or other allied health professional.

Denial Risk

Student and Aide Services

Services performed by a student are not covered and must not be billed, even when provided under line-of-sight supervision by a licensed registered occupational therapist or OTA. The presence of a student in the room does not by itself make an otherwise covered service unbillable; services performed by an aide are not billable even when the aide is supervised by a licensed registered occupational therapist or OTA.

Do not bill any portion of a service performed by a student, including under line-of-sight supervision.
Do not bill services performed by an aide, regardless of supervision.
A student’s presence alone does not make a service unbillable when the covered service is performed by an eligible practitioner.

Continuing responsibilitiesTraining the OTA who performs the services and maintaining necessary equipment and supplies remain the supervising therapist's responsibility

Occupational Therapist in Private Practice (OTPP)

State authorizationThe occupational therapist is legally authorized by the state to engage in private practice and practices only within the scope of licensure

Practice structureThe therapist regularly practices individually, in a solo practice, partnership, or group practice, or as an employee of one of these

Billing locationThe therapist bills TRICARE only for services furnished in the private practice office space or the patient's home

Office spacePrivate practice office space is owned, leased, or rented by the practice and used exclusively to operate the practice

Furnished in whole or in part by an OTA

All service minutesThe OTA furnishes all minutes of a service exclusive of the occupational therapist

Separate portionThe OTA furnishes a separate portion of a service from the portion furnished by the occupational therapist

Qualifying thresholdThe OTA's separate portion exceeds 10% of the total service minutes