Physical therapy is covered to aid in the recovery from disease or injury to help the patient in attaining greater self-sufficiency, mobility and productivity by improving muscle strength, joint motion, coordination, and endurance. Physical therapy is covered when rendered and billed by a licensed, registered physical therapist or other authorized professional provider acting within the scope of his or her license. Professional services performed by a supervised licensed physical therapy assistant (PTA) must be billed under the licensed physical therapist’s National Provider Identification (NPI) number using the CQ modifier. PTAs may not provide an initial examination, evaluation, assessment, or establish a diagnosis or plan of care.
Outpatient therapy is authorized based on one visit per day. All active duty service members (ADSMs), TRICARE Prime and TRICARE Prime Remote beneficiaries who have an assigned primary care manager (PCM) require an approval from Health Net Federal Services, LLC (HNFS) for physical therapy services. TRICARE Prime Remote beneficiaries (excluding ADSMs) without an assigned PCM and TRICARE Select beneficiaries do not require an approval from HNFS prior to services being rendered; however, a physician’s order is required for claims processing.
Coverage is based on the beneficiary's medical needs. The number of visits authorized indicates the actual number of visits, not the individual units per CPT® code. The following baselines will be used as a guide for the number of visits and duration of approval:
- Acute injuries (for example, musculoskeletal conditions such as ankle sprain, shoulder sprain, low back pain or torn hamstring) = 12 visits with a duration of 120 days
- Post-operative care (for example, hip and knee replacement) = 24 visits with a duration of 150 days
- Long term conditions (for example, neurological conditions such as stroke, traumatic brain or spinal cord injury, pediatric neurodevelopmental conditions, swallow testing or feeding therapy) = 72 visits with a duration of 180 days
Individualized Education Program Requirements
Physical therapy to treat a physical or occupational deficiency due to a cognitive or developmental disorder for beneficiaries age three to 21 requires a physician letter of attestation whenever there is evidence presented to TRICARE that there is an individualized education program in place for special education services. TRICARE may cover additional physical therapy when a physician attests in writing the intensity and/or timeliness of any physical therapy services being offered by the educational agency does not meet the medical needs of the beneficiary.
- diathermy, ultrasound and heat treatments for pulmonary conditions
- general exercise programs
- electrical nerve stimulation used in the treatment of upper motor neuron disorders such as multiple sclerosis
- separate charges for instruction of the patient and family in therapy procedures
- repetitive exercise to improve gait, maintain strength and endurance, and assistive walking such as that provided in support of feeble or unstable patients
- range of motion and passive exercises, which are not related to restoration of a specific loss of function
- maintenance therapy that does not require a skilled level of assistance
- vocational assessment and training or assessments to determine status of disability
- athletic training evaluation (CPT 97005 and 97006)
- CPT 97532 or 97533 when used to improve cognitive function as a result of neuronal growth through the repetitive exercise of neuronal circuits
- CPT 97532 or 97533 for sensory integration training
- services provided to address disorders or conditions resulting from occupational deficits
Low Back Pain Physical Therapy Demonstration
The Defense Health Agency (DHA) has authorized a “Low Back Pain Physical Therapy Demonstration” that will waive cost-sharing for up to three PT visits for patients with low back pain. Currently this waiver only applies to Arizona, California and Colorado in the West region. The aim of this demonstration is to evaluate whether waiving the costs for beneficiaries increases participation, decreases low-value care, and/or decreases the overall cost of care for treating patients with low back pain.
- Applies to new PT episodes of care on or after Jan. 1, 2021.
- Care must be referred by a TRICARE-authorized provider.
- Care must be rendered by a network provider. (Exception: TRICARE For Life beneficiaries may receive care from any TRICARE-authorized PT provider.)
Note: After the third PT session, beneficiaries will be responsible for their regular cost-share amount for future sessions.
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