Outpatient Physical Therapy Changes Effective June 13th, 2017

June 30th, 2017 - Shannon DeConda
Categories:   Physical Medicine|Physical Therapy   Audits/Auditing  
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Our friends in clinics operating in Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or in a rural area have long struggled with how to cover Physical Therapy services when a therapist is on leave, vacation, or in event of medical leave. The Centers for Medicare and Medicaid Services (CMS) has now made this coverage easier for those who meet the qualification of HPSA, MUA, or RHC by allowing these services to be billed under reciprocal billing guidelines.

As a reminder, Reciprocal Billing (RB), a provision allowed by Section 1842(b)(6)(D) of the Social Security Act (the Act) has historically allowed payment to be made to a physician for physician's services furnished by a another physician to patients of the first physician when the first physician is unavailable due to leave, vacation, deployment, or otherwise. The services are furnished through an arrangement between to the two providers which may allow payment to the other provider either in an informal manner or in a per diem or other fee-for-time compensation for such services.

RB is only allowed for a continuous period of no more than 60 days, however this new change provides a new allowance for the length of time RB may be used. The new guidance indicates that if the regular physician is called or ordered to active duty as a member of a reserve component of the Armed Forces, RB may be used "throughout that entire period."

MACs will accept claims from Physical Therapists, who bill with Provider Specialty code 65, which are Physical Therapist in Private Practice, for RB arrangements under this new provision by submitting their services utilizing the Q5 modifier. However, if the Physical Therapist arrangement is based on fee- for-time compensation arrangements the claim should include the Q6 modifier. The MACs understand that currently the Q5 and Q6 Modifier Descriptors refer to physician use only, but they will accept claims from physical therapists that are reported with a Q5 or Q6. Also noted in this update is that formal changes to these modifiers are coming.

For complete details regarding these upcoming changes, here is a link to the full update provided by CMS: https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-


At NAMAS, we strive to provide training and education for medical auditors and compliance professionals- regardless of their specialty. We're happy to announce that during our 9th Annual Auditing & Compliance Conference which will be held December 5-8, 2017 in Orlando, FL at the Loews Sapphire Falls Resort, we will be offering an educational track specific to FQHC and Rural Health auditing. This focused track will occur during our pre-conference event on Tuesday, December 5, 2017. Click here to view our conference agenda - we invite you to consider attending this one of a kind educational experience! Conference details are provided below in this week's tip.


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