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BCBS Arkansas - “Incident to” services, performed by Physical Therapist Assistants (PTAs) and Certified Occupational Therapist Assistants (COTAs)

1 Oct 2024 3:42 PM | Zachary Edgar (Administrator)

Effective November 1, 2024, “Incident to” services, performed by Physical Therapist Assistants (PTAs) and Certified Occupational Therapist Assistants (COTAs) under the general supervision of a supervising Physical Therapist or Occupational Therapist are eligible for separate reimbursement when separately reported by the supervising provider when the service performed is an otherwise covered service.

Services performed in whole or in part by a PTA or COTA will be required to be billed with the appropriate modifier CQ or CO and will be subject to the payment policy guidelines. When covered “Incident to” services are rendered in accordance with the policy, the services will be reimbursed at 85% of the PT/OT calculated allowable.

“Incident to” services must meet the following criteria:

  • HCPCS modifiers CQ and CO are required to be used for services furnished In Whole or In Part by a Physical Therapy Assistant (PTA) or Certified Occupational Therapy Assistant (COTA). 
  • Services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.
  • Services provided by PTAs and COTAs must fall within the scope and definition of covered services under the written terms of the member’s benefit certificate.
  • Services provided by PTAs and COTAs must not fall within the scope or definition of any exclusion in the member’s benefit certificate (other than the definition of “provider”).
  • All services provided by PTAs and COTAs must be supervised by a licensed therapist (applicable to the specific licensure of the assistant) present in the office suite and/or immediately available, when necessary, via interactive audiovisual telecommunication to provide assistance and direction throughout visit or rendered service.
  • PTAs and COTAs must hold an active and unrestricted license to perform physical therapy or occupational therapy assistant services, in full compliance with applicable state laws and regulations.
  • The supervising licensed physical therapist or occupational therapist must bill for services provided by PTAs and COTAs. PTAs and COTAs may not bill separately or directly for any services performed.
  • The service provided must be one that is included in the CPT/HCPCS section of the payment policy.

The following services are not eligible for reimbursement as “Incident to” services:

  • Services performed by auxiliary personnel other than PTAs or COTAs, including physical or occupational therapy aides.
  • Incidental services that are not separately reportable.
  • Services provided by PTAs and COTAs will not be covered or reimbursed if services include any evaluation or assessment services or if services include the PTA or COTA making clinical judgments or decisions regarding the member’s care or treatment.- Physical Therapy evaluation codes include CPT codes 97161-97164 - Occupational Therapy evaluation codes include CPT codes 97165-97168.
  • Services provided by PTAs and COTAs will not be covered or reimbursed if the services include the development, management or furnishing of any skilled maintenance program services or if the services include the PTA or COTA taking or asserting overall responsibility for services.
  • The services of a PTA/OTA cannot be provided incidental to a physician/appropriately licensed other practitioner as they are not specifically qualified as licensed physical therapists or occupational therapists


About Us

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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