Outpatient Physical Therapy (OPT) Reciprocal Billing Arrangements and Fee-For-Time Compensation
Under section 16006 of the 21st Century Cures Act, a physical therapist enrolled in Medicare may use a substitute physical therapist to provide physical therapy services in a designated Health Professional Shortage Area (HPSA). They may also provide substitute services in 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.
This can be very helpful if your group is located in one of these designated areas and find yourself in need of a substitute therapist. This is most often used when a therapist employed by your group has to take an unexpected leave of absence. Be sure to always document and notate in your patient record when this is done.
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:
- 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.
- 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.
There is an exception to the 60 day rule for reciprocal billing for a therapist that is called to serve in the military. The active duty exception allows you to bill for an extended period beyond the 60 day limitation.
Continuous Period of Covered Visit Services:
This period begins with the first day on which the substitute physical therapist provides covered visit services to Medicare Part B patients that would normally be seen by the employed physical therapist, and ends with the last day the physical therapist providing substitute services treats your patients. This period continues without interruption on days on which no covered visit services are provided to patients on behalf of the regular physical therapist or are furnished by some other physical therapist on behalf of the regular physical therapist. A new period of covered visit services can begin after the regular physical therapist has returned to work.
A record of each service provided by the substitute physical therapist must be kept on file along with the substitute therapist’s NPI. This record must be made available upon request.
- 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))