Outpatient Physical Therapy (OPT) Reciprocal Billing Arrangements and Fee-For-Time Compensation

Under section 16006 of the 21st Century Cures Act, a Medicare-enrolled physical therapist may use a substitute physical therapist to furnish outpatient physical therapy services in a Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or a rural area under a reciprocal billing arrangement on/after June 13, 2017. Reciprocal Billing arrangements or Fee-for-Time Compensation (formerly Locum Tenens) has been only for physicians use.

In the CMS Internet, Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 30.2.1; 30.2.10; 30.2.11; 30.2.13; and 30.2.14 the significant difference between "fee for time compensation" and "reciprocal" billing are as follows:

  1. Fee-for-time compensation is on a per-diem rate billing under the National Provider Identifier (NPI) of the physical therapist for which they are replacing.

    In a reciprocal arrangement, each physical therapist continues to bill all services to his or her own patients. When group billing, the substitute, provider must reassign their benefits to the group to bill reciprocally.
     
  2. Fee-for-time compensation services are identified by appending HCPCS modifier-Q6 (Service furnished by a substitute physician/physical therapist), whereas the reciprocal billing arrangement is indicated with modifier-Q5 (Service furnished by a substitute physician/physical therapist under a reciprocal billing arrangement). This is required on the form CMS-1500 or 837P equivalent.

    Services provided by a substitute physical therapist may be reimbursed if:
    • The regular physician/physical therapist is unavailable to provide the services;
    • The Medicare patient has arranged or seeks to receive the services from the regular physical therapist;
    • The substitute physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days.

Note: Exception to the 60-continuous rule is for a physician or physical therapist called to active duty in the Armed Forces a substitute may bill for services furnished under a substitute billing arrangement for longer than the 60-day limit.

Defining "continuous period of covered visit services" begins with the first day on which the substitute physician or physical therapist provides covered visit services to Medicare Part B patients of the regular physician or physical therapist, and ends with the last day the substitute physician or physical therapist provides services to such patients before the regular physician or physical therapist returns to work. This period continues without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or physical therapist or are furnished by some other substitute physician or physical therapist on behalf of the regular physician or physical therapist. A new period of covered visit services can begin after the regular physician or physical therapist has returned to work.

A record of each service provided by the substitute physician or physical therapist must be kept on file along with the substitute therapist's NPI. This record must be made available upon request.

Resources

  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 30.2; 30.2.1; 30.2.10; 30.2.11; 30.2.13; and 30.2.14
  • CMS Change Request (CR)100090 - Changes to the Payment Policies for Reciprocal Billing Arrangements and Fee-For-Time
  • Compensation Arrangements (formerly referred to as Locum Tenens Arrangements (effective 5/12/17))

 

Last Updated Thu, 25 Oct 2018 13:24:40 +0000