ModifiedDHAPolicy 6010.63-M

Physical Therapist Assistants (PTAs)

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Reimbursement and billing requirements for services involving physical therapist assistants under the TRICARE program.

Policy Summary

PayerDHA

PolicyPhysical Therapist Assistants (PTAs)

Policy CodePolicy 6010.63-M

Change TypeModified

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionApply general supervision for qualifying private-practice PTA arrangements beginning January 1, 2025, while following any more stringent state or local requirements.

SourceLink

POLICY UPDATE CHANGES

Supervision for PTAs working under physical therapists in private practice changed from direct supervision through December 31, 2024, to general supervision beginning January 1, 2025.

Rev. 57Policy manual revision

5Expressly prohibited PTA activities

>10%Modifier CQ threshold

30 daysRequired reassessment or supervisory interval

CMACPTA claim reimbursement class

Policy Summary

PayerDHA

PolicyPhysical Therapist Assistants (PTAs)

Policy CodePolicy 6010.63-M

Change TypeModified

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionApply general supervision for qualifying private-practice PTA arrangements beginning January 1, 2025, while following any more stringent state or local requirements.

SourceLink

On This Page

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ModifiedDHAPolicy 6010.63-M

Physical Therapist Assistants (PTAs)

Customize your policy alerts

Sign up for DHA Policy 6010.63-M alerts

Get alerted when Policy 6010.63-M changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Reimbursement and billing requirements for services involving physical therapist assistants under the TRICARE program.

Policy Summary

PayerDHA

PolicyPhysical Therapist Assistants (PTAs)

Policy CodePolicy 6010.63-M

Change TypeModified

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionApply general supervision for qualifying private-practice PTA arrangements beginning January 1, 2025, while following any more stringent state or local requirements.

SourceLink

POLICY UPDATE CHANGES

Supervision for PTAs working under physical therapists in private practice changed from direct supervision through December 31, 2024, to general supervision beginning January 1, 2025.

Rev. 57Policy manual revision

5Expressly prohibited PTA activities

>10%Modifier CQ threshold

30 daysRequired reassessment or supervisory interval

CMACPTA claim reimbursement class

Policy Summary

PayerDHA

PolicyPhysical Therapist Assistants (PTAs)

Policy CodePolicy 6010.63-M

Change TypeModified

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionApply general supervision for qualifying private-practice PTA arrangements beginning January 1, 2025, while following any more stringent state or local requirements.

SourceLink

On This Page

1Therapy codes for shared time interval

Covered and Nonbillable PTA Services

Covered PTA services

PTA services may be reimbursed when all applicable qualification, scope-of-practice, supervision, documentation, and billing requirements are met.

ALL of the following

The PTA meets Medicare qualification requirements under 42 CFR 484.115 or a successor regulation and applicable state licensure and scope-of-practice requirements.
The PTA is supervised by a licensed registered physical therapist under the supervision requirements applicable to the provider type.
The services are skilled rehabilitative therapy services and are not services that can safely and effectively be furnished by nonskilled personnel or by a PTA without licensed registered physical therapist supervision.
Professional services are billed under the supervising licensed registered physical therapist's NPI, and the required documentation and certification are complete.
Outpatient physical therapy services furnished in whole or in part by a PTA are billed with modifier CQ when the PTA furnishes more than 10% of the service, including all service minutes exclusive of the physical therapist or a separately performed portion exceeding 10% of total service minutes.

Excluded or nonbillable services

The following services or billing arrangements are not covered or are not billable as PTA rehabilitative therapy services.

ANY of the following

Services that can safely and effectively be furnished by nonskilled personnel or by a PTA without licensed registered physical therapist supervision.
PTA services billed as incident to or under the supervision of a physician or other allied health professional.
Services performed by a student, even when provided under line-of-sight supervision by a licensed registered physical therapist or PTA; however, a student's presence in the room alone does not make an otherwise billable service unbillable.
Services performed by an aide, even when supervised by a licensed registered physical therapist or PTA.
A PTA performs an initial examination, evaluation, re-evaluation or assessment, establishes a diagnosis, or establishes a plan of care.

Billing and Coding Requirements

PTA service modifierModifierCovered

CQ	Modifier for outpatient physical therapy services furnished in whole or in part by a PTA

Billing provider identifiermixedCovered

Supervising physical therapist NPI

The supervising licensed registered physical therapist's NPI must be used for professional PTA services billed under CMAC

PTA service-time threshold for modifier CQ

ModifierModifier CQ is required for outpatient physical therapy services furnished in whole or in part by a PTA.

Percentage thresholdThe PTA-furnished portion exceeds 10% of the total service minutes.

Exclusive-minutes thresholdThe PTA furnishes all service minutes exclusive of the physical therapist.

Home health physical therapist reassessment interval

Reassessment frequencyAt least once every 30 calendar days.

Responsible professionalThe licensed registered physical therapist, not the PTA, must provide the ordered therapy service.

Provider Responsibilities

Documentation Required

Verify PTA qualifications

Verify that each PTA meets Medicare qualification requirements under Title 42 CFR 484.115 or a successor regulation before services are billed.

Documentation Required

Maintain licensure and supervision

Ensure each PTA works within applicable state licensure and scope-of-practice requirements and is supervised by a licensed registered physical therapist. More stringent state or local laws or regulations must be followed.

Billing Rule

Key Terms

Direct supervision

LocationThe supervising physical therapist must be in the office suite where the PTA is located.

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

Same-room requirementThe physical therapist is not required to be in the room with the PTA while services are performed.

General supervision

Direction and controlServices are furnished by the PTA under the physical therapist's overall direction and control.

Presence during servicesThe physical therapist's presence is not required during performance of the services.

Reassessment purposeFunctionally reassess the patient and compare new measurements with previous measurements.

Rehabilitation agency off-site supervisory visit interval

Supervisory visit frequencyAn on-site supervisory visit is required at least once every 30 calendar days when a PTA provides services off the rehabilitation agency's premises.

Supervising professionalThe visit must be made by a licensed registered physical therapist.

State or local lawVisits must occur more frequently if required by state or local laws or regulation.

Therapy code count per shared time interval

Code submissionOnly one therapy code may be submitted for a shared time interval.

Shared intervalThe rule applies when a particular therapy requires both a licensed registered physical therapist and a PTA during one time interval.

Separate reimbursementThe physical therapist and PTA may not be separately reimbursed for the same time interval.

Apply provider-specific supervision rules

Apply the supervision standard applicable to the provider type and setting. General supervision is required for institutional providers and for qualifying private-practice arrangements beginning January 1, 2025; additional requirements apply to HHAs, CORFs, rehabilitation agencies, and other CSPs.

For a qualifying physical therapist in private practice, general supervision is required beginning January 1, 2025.
Institutional providers and CSPs generally require general supervision, subject to the applicable provider-specific requirements.
Follow more stringent state or local supervision requirements when they apply.

Documentation Required

Perform required home health reassessments

For home health agencies, the licensed registered physical therapist—not the PTA—must provide the ordered therapy service at least once every 30 calendar days to functionally reassess the patient and compare new measurements with previous measurements.

Maintain medical records and document services as required by the Medicare Conditions of Participation at 42 CFR 484.110 or a successor regulation.
If this policy conflicts with Medicare HHA requirements, Medicare requirements take precedence.

Billing Rule

Meet facility-specific oversight requirements

Meet the oversight requirements specific to CORFs and rehabilitation agencies. CORF physical therapy services require the physical therapist to be on the premises or available through direct telecommunications during operating hours; rehabilitation agencies must ensure therapist availability and required off-site supervisory visits.

For rehabilitation agency services furnished off the organization's premises, schedule an on-site supervisory visit at least once every 30 calendar days, or more frequently if required by state or local law or regulation.
When the therapist is not on the premises during all hours of operation, schedule patients so the therapist is present when special skills are needed, such as evaluation and reevaluation.

Billing Rule

Append modifier CQ when required

Bill outpatient physical therapy services furnished in whole or in part by a PTA using modifier CQ when the PTA furnishes all service minutes exclusive of the physical therapist or furnishes a separately performed portion exceeding 10% of the total service minutes.

Use modifier CQ when more than 10% of the service is furnished by the PTA.
Claims with modifier CQ for services rendered on or after January 1, 2022 are reimbursed at the non-physician class CMAC for the applicable service.

Documentation Required

Submit claims under supervising therapist

Bill CMAC professional PTA services under the supervising licensed registered physical therapist's National Provider Identifier (NPI). The supervising therapist certifies that the claim is accurate, supporting documentation is complete, and the services were provided under the required supervision.

Billing Rule

Avoid duplicate time-interval billing

When a therapy service requires both a physical therapist and a PTA during one time interval, submit only one code for that interval. The physical therapist and PTA may not be separately reimbursed for the same interval.

Denial Risk

Exclude student and aide services

Do not bill services performed by a student or aide, even when supervised by a licensed registered physical therapist or PTA. The presence of a student in the room alone does not make an otherwise billable service unbillable.

Student services are not covered and may not be billed, including when provided under line-of-sight supervision.
Aide services may not be billed even when supervised by a licensed registered physical therapist or PTA.

Continuing responsibilitiesThe supervising physical therapist remains responsible for PTA training and maintenance of necessary equipment and supplies.

Physical Therapist in Private Practice (PTPP)

LicensureThe physical therapist is legally authorized by the state to engage in private practice and practices only within the scope of licensure.

Practice statusThe physical therapist regularly practices as an individual in a solo, partnership, or group practice, or as an employee of one of these.

TRICARE billing locationsTRICARE is billed only for services furnished in the private practice office space or in the patient's home.

Patient's home

Included settingA patient's home is a residence where the patient's home-based therapy services are furnished.

Hospital exclusionA patient's home does not include a hospital.

Other institutional exclusionsA patient's home does not include a critical access hospital or a skilled nursing facility.

Corporate Service Provider (CSP)

General ruleGeneral supervision is required for a CSP in all settings other than a qualifying PTPP.

PTPP exceptionIf a provider considered a CSP meets the requirements of a PTPP, the PTPP supervision rules apply.

Similar Medicare provider typesA substantially similar CSP provider type must meet Medicare supervision requirements unless those requirements are less stringent than the requirements in this section.