Medicare Extends Reciprocal and Fee-for-Time Arrangements to PTs

12 Jun 2017

CMS announced in a recent transmittal its implementation of a provision in the 21st Century Cures Act which will allow outpatient physical therapy services furnished by PTs in health professional shortage areas (HPSA), medically underserved areas (MUA), or in rural areas to be billed under reciprocal billing and fee-for-time compensation arrangements in the same manner as physicians, effective no later than June 13, 2017.    Reciprocal billing arrangements are those in which providers reciprocally see the patients of the other provider when the therapist is out of the office.  Fee-for-time arrangements (formerly known as locum tenens arrangements) are those in which a provider has another provider, e.g. a contract or PRN provider, treat his/her patients during a temporary absence.  The provision will allow PTs to submit claims under their NPI number for covered visit services provided by a substitute, licensed physical therapist during temporary absences for illness, pregnancy, vacation, or continued education.

The transmittal released by CMS includes requirements for both reciprocal and fee-for-time arrangements.  For the purposes of today’s post, we will focus primarily on CMS’s instructions pertaining to fee-for-time arrangements.  Per the transmittal, the general requirements which are applicable to all fee-for-time compensation arrangements state that a patient’s regular physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services of a substitute physician or physical therapist, if:

  • The regular physical therapist is unavailable to provide the services;
  • The Medicare beneficiary has arranged or seeks to receive the services from the regular physical therapist;
  • The regular physical therapist pays the substitute for his/her services on a per diem or similar fee-for-time basis;
  • The substitute physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days subject to the following exception: A physical therapist called to active duty in the Armed Forces may bill for services furnished under a fee-for-time compensation arrangement for longer than the 60-day limit; and
  • The regular physical therapist indicates that the services were provided by a substitute physical therapist under a fee-for-time compensation arrangement meeting the requirements of this section by entering a Q6 modifier after the procedure code.

In order for a medical group or physical therapy group to submit claims in the name of the regular physical therapist for the services of a substitute physical therapist, the substitute physical therapist may not have reassigned his or her right to Medicare payment to the group through a CMS-855R reassignment enrollment form approved by the A/B MACs Part B and the following requirements must be met:

  • The regular physical therapist is unavailable to provide the services;
  • The Medicare patient has arranged or seeks to receive the services from the regular physical therapist; and
  • The substitute physician physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days subject to the following exception: A physical therapist called to active duty in the Armed Forces may bill for services furnished under a fee-for-time compensation arrangement for longer than the 60-day limit.

For purposes of these requirements, per diem or similar fee-for-time compensation which the group pays the substitute is considered paid by the regular physical therapist. Also, a physical therapist who has left the group and for whom the group has engaged a substitute as a temporary replacement may bill for the temporary physical therapist for up to 60 days. The term “regular physical therapist” includes a physical therapist who has left the group and for whom the group has hired the substitute as a replacement.

Services are billed for the entity as follows:

  • The medical group or physical therapy group must enter in item 24d of Form CMS-1500 the HCPCS code modifier Q6 after the procedure code.
  • A record of each service provided by the substitute physical therapist must be kept on file along with the substitute physical therapist’s NPI. This record must be made available to the A/B MACs Part B upon request.
  • In addition, the medical group physician or group physical therapist on whose behalf the services were furnished by a substitute must be identified by his/her NPI in block 24J of the appropriate line item.

Lastly, it is important to keep in mind that this change is limited to areas of the country designated as health professional shortage areas (HPSA), medically underserved areas (MUA), or rural areas.  To determine if your clinic is in an HPSA or MUA, visit the Health Resources and Service Administration (HRSA) website.  To determine if your clinic is in a rural area, visit CMS’s Final Rule Data Files webpage and click the download link titled “County to CBSA Crosswalk File and Urban CBSAs and Constituent Counties for Acute Care Hospitals”.  Counties for which there is nothing listed in column F of that file are designated as rural.