In news long awaited by physical therapists in private practice, the Centers for Medicare & Medicaid Services (CMS) has released guidance implementing rules for the policy informally known as “locum tenens,” Latin for “to hold the place of, to substitute for.” 

Beginning on June 13, physical therapists (PTs) will be able to utilize another licensed PT to treat Medicare patients when there is a temporary absence for illness, vacation, or continuing medical education. The good news is that Medicare can be billed for these therapy services provided by the “substitute” PT; the bad news is that this new change is limited to certain parts of the country designated by CMS as a Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or in an otherwise rural area.

The details of the implementation, per the 21st Century Cures Act, are outlined by CMS in MLN Article MM10090. CMS also announced the retiring of the term “locum tenens” as a result of the language used in the 21st Century Cures Act, which uses the term “locum tenens arrangements” to refer to both fee-for time compensation arrangements and reciprocal billing arrangements. CMS also indicated in the article that “continuing to use the term ‘locum tenens’ to refer solely to fee-for-time compensation arrangements is not consistent with the new law and could be confusing to the public.” 

Relevant sections of the Medicare Claims Processing Manual will be updated, per Transmittal R3774CP.  Additionally, CMS has clarified that for circumstances in which “a regular physician or physical therapist is called or ordered to active duty as a member of a reserve component of the Armed Forces for a continuous period of longer than 60 days, payment may be made to that regular physician or physical therapist for services furnished by a substitute under reciprocal billing arrangements or fee-for-time compensation arrangements throughout that entire period.”

According to the American Physical Therapy Association (APTA), “PTs can find out if they’re practicing in a HPSA or MUA by visiting the Health Resources and Service Administration (HRSA) website.”

“Finding out about rural areas is a little trickier: the information is available on a webpage devoted to the final rule’s data files,” the APTA continued. “To get at the Excel file with the relevant information, scroll down to a gray ‘Downloads’ box and open a file titled ‘County to CBSA crosswalk file and urban CBSAs and constituent counties for acute care hospitals.’ The areas left blank in the Excel sheet are the ones CMS has designated as rural.”

How to Bill

Medicare Administrative Contractors (MACs) will accept claims from physical therapists in private practice (Provider Specialty Type 65) for reciprocal billing arrangements, when submitted with the Q5 and Q6 modifiers for fee-for-time compensation arrangements. CMS has stated that the description for both the Q5 and Q6 modifiers will be amended to include physical therapists, in addition to physicians, in a future Healthcare Common Procedure Coding System (HCPCS) quarterly update. These modifiers are to be used in addition to the GP modifier used to indicate that a service was provided by a physician therapist, the KX modifier indicating that therapy over the cap is medically necessary, and the -59 modifier used to appropriately unbundle code pairs subject to the CCI edits.

Just in case you were wondering, your questions have been anticipated:

  1. Does this also apply to occupational therapists (OTs) or speech-language pathologists (SLPs) in private practice? No, unfortunately, this was legislation championed by the APTA for some time and did not include provisions for OTs. This is a great time to lobby the American Occupational Therapy Association (AOTA) or the American Speech-Language Hearing Association (ASHA) to include provisions for “locum tenens” in their legislative agendas.
  1. Does this include hospital therapists? No, this provision is only for therapists in private practice (enrolled in Medicare as a supplier) who are billing on the CMS 1500 claim form. Therapists working for institutional providers such as hospitals, skilled nursing facilities, CORFs, rehab agencies, or home health agencies do not bill Medicare directly, as the facility bills Medicare on the UB04 claim form. Facilities have always been able to use substitute or temporary staff, including those from a registry service.
  1. Does this allow for substitute physical therapist assistants (PTAs)? No, since PTAs do not have billing privileges with Medicare there is no need to provide for temporary billing privileges. A therapy practice can always bring on a temporary or substitute PTA, as the claims are billed under the credentials of the physical therapists providing direct supervision.

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