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TRICARE Policy Manual 6010.60-M, April 1, 2015
Providers
Chapter 11
Section 3.17
Occupational Therapy Assistants (OTAs)
Issue Date:  April 22, 2020
Authority:  32 CFR 199.4(c)(3)(x) and 32 CFR 199.6(c)(3)(iii)(K)(2)(ii)
Revision:  C-62, April 22, 2020
1.0  BACKGROUND
The National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2018, Section 721, was signed into law on December 12, 2017. The NDAA authorized the TRICARE program to cover the services of a qualified OTA when supervised by a licensed registered occupational therapist.
2.0  QUALIFICATIONS
OTAs shall meet Medicare’s requirements for qualification as required by NDAA FY 2018, Section 721. Medicare’s requirements for qualification can be found at Title 42, Code of Federal Regulations (CFR), Section 484.115 or successor regulation.
3.0  SCOPE OF PRACTICE
OTAs shall work within the requirements established by their state licensure and scope of practice. OTAs shall not perform the following tasks:
•  Initial examination
•  Evaluation
•  Re-evaluation and assessment
•  Establish a diagnosis
•  Establish a plan of care
4.0  SUPERVISION
4.1  An OTA shall be supervised by a licensed registered occupational therapist.
4.2  The requirements set below apply unless state or local laws or regulations are more stringent, in which case state or local requirements shall be followed.
4.3  The number of OTAs working under the supervision of a licensed registered occupational therapist shall be reasonable to ensure adequate supervision.
4.4  Supervision definitions.
4.4.1  Direct Supervision. Direct supervision requires the supervising occupational therapist to be in the office suite where the OTA is located and immediately available to furnish assistance and direction throughout performance of the services. The occupational therapist is not required to be in the room with the OTA while the services are performed.
4.4.2  General Supervision. General supervision means the services are furnished by the OTA under the occupational therapist’s overall direction and control, but the occupational therapist’s presence is not required during the performance of the services. Under general supervision, the training of the OTA who actually performs the services and maintenance of the necessary equipment and supplies are the continuing responsibility of the supervising occupational therapist.
4.5  Supervision requirements by type of provider.
4.5.1  Occupational Therapists in Private Practice (OTPP) as defined below.
4.5.1.1  Direct supervision is required for OTAs supervised by OTPPs.
4.5.1.2  A licensed registered occupational therapist is considered to be an OTPP if the occupational therapist meets the following requirements:
4.5.1.2.1  Legally authorized to engage in the private practice of occupational therapy by the state in which he or she practices, and practices only within the scope of his or her licensure.
4.5.1.2.2  Engages in the private practice of occupational therapy on a regular basis as an individual, in one of the following practice types: a solo practice, partnership, or group practice; or, as an employee of one of these.
4.5.1.2.3  Bills TRICARE only for services furnished in his or her private practice office space, or in the patient’s home. Private practice office space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice. A patient’s home does not include any institution that is a hospital, critical access hospital, or a skilled nursing facility.
4.5.2  Institutional providers.
4.5.2.1  General supervision is required.
4.5.2.2  Home Health Agencies (HHAs).
4.5.2.2.1  In addition to the requirement for general supervision, the licensed registered occupational therapist (not the OTA) shall provide the ordered therapy service at least once every thirty days to functionally reassess the patient and compare the new measurements to the previous measurements.
4.5.2.2.2  It shall be the responsibility of the HHA for ensuring services are provided in accordance with the requirements outlined in the Medicare Benefit Policy Manual, Chapter 7, “Home Health Services” (or successor policy). HHAs shall also be responsible for maintaining medical records and ensuring all records are documented as required by the Medicare Conditions of Participation at 42 CFR 484.110, or successor regulation
4.5.2.2.3  If there is conflict between this section and Medicare’s requirements for HHAs, Medicare’s requirements shall take precedence.
4.5.3  Corporate Service Providers (CSPs).
4.5.3.1  General supervision is required for all settings other than an OTPP. If a provider is considered by TRICARE to be a CSP, but meets the requirements of an OTPP, the supervision rules for an OTPP apply.
4.5.3.2  Comprehensive Outpatient Rehabilitation Facilities (CORFs). In addition to the requirement for general supervision, CORF occupational therapy services require that the occupational therapist be on the premises of the CORF or shall be available to the OTA through direct telecommunications for consultation and assistance during the CORF’s operating hours.
4.5.3.3  Rehabilitation Agencies. In addition to the requirement for general supervision, the following requirements also apply:
4.5.3.3.1  A licensed registered occupational therapist is present or readily available to offer supervision when an OTA furnishes services.
4.5.3.3.2  If a licensed registered occupational therapist is not on the premises during all hours of operation, patients are scheduled so as to ensure that the therapist is present when special skills are needed, for example, for evaluation and reevaluation.
4.5.3.3.3  When an OTA provides services off the organization’s premises, those services are supervised by a licensed registered occupational therapist who makes an on-site supervisory visit at least once every 30 days (or more frequently if required by state or local laws or regulation).
4.5.3.4  Other CSPs. When a type of CSP not specifically listed here is of a provider-type that is substantially similar to a provider-type certified by Medicare, the provider and its OTAs shall meet any supervision requirements established by Medicare in Medicare’s regulations or policy manuals for that type of provider, unless those requirements are less stringent than those offered in this Section.
5.0  REIMBURSEMENT
5.1  TRICARE is required by law to reimburse like Medicare where practicable (10 USC 1079 (h)). Medicare reimburses for the services of OTAs; as such, it is practicable for TRICARE to reimburse like Medicare for services provided by OTAs.
5.2  Where a Prospective Payment System (PPS) applies, therapy services are paid in accordance with that PPS so long as services conform to any requirements within the PPS.
5.3  Professional services performed by an OTA meeting applicable supervision requirements, and billed under the CHAMPUS Maximum Allowable Charge (CMAC) shall be billed under the supervising licensed registered occupational therapist’s National Provider Identification (NPI) number.
5.3.1  Outpatient occupational therapy services furnished in whole or in part by an OTA shall be billed using the modifier CO. A service is considered to be furnished in whole or in part by an OTA when more than 10% of the service is furnished by the OTA. In accordance with Medicare’s guidelines, “furnished in whole or in part” means the OTA either:
5.3.1.1  Furnishes all the minutes of a service exclusive of the occupational therapist; or
5.3.1.2  Furnishes a portion of a service separately from the part furnished by the occupational therapist such that the minutes for that portion of a service furnished by the OTA exceed 10% of the total minutes for that service.
5.3.2  Effective for services rendered on or after January 1, 2022, claims with a modifier of CO shall be reimbursed at the non-physician class CMAC for the applicable service.
5.4  The time counted is the time the patient is treated. If a particular therapy requires both a licensed registered occupational therapist and an OTA for one time-interval (or two occupational therapists or two OTAs), only one code shall be submitted for that time-interval (i.e., the occupational therapist and the OTA shall not be separately reimbursed).
5.5  When OTA services are provided under supervision of a licensed registered occupational therapist and NPI number, the licensed registered occupational therapist certifies that the claim is accurate, all documentation to support the claim has been completed, and that the services were provided by the licensed registered occupational therapist or that an OTA provided the services under supervision as required by this section.
6.0  EXCLUSIONS
6.1  Services that can be safely and effectively furnished by nonskilled personnel or by an OTA without the supervision of the licensed registered occupational therapist are not covered rehabilitative therapy services and are excluded from coverage.
6.2  The services of an OTA shall not be billed as services incident to or under the supervision of a physician or other allied health professional because physicians and other allied health professionals do not meet the qualifications for a licensed registered occupational therapist.
6.3  Services performed by a student are not covered and shall not be billed even if provided under line of sight supervision by a licensed registered occupational therapist or OTA; however, the presence of a student in the room does not make the service unbillable.
6.4  The services of an aide shall not be billed even if supervised by a licensed registered occupational therapist or OTA.
7.0  EFFECTIVE DATE
April 16, 2020.
- END -

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