Billing and Coding: Therapy Students and Aides

Coverage and documentation requirements for the provision of services by/or in
the presence of a therapy student or therapy aide in both inpatient and
outpatient therapy settings.  
  

  * Inpatient: Inpatient Skilled Nursing Facility (SNF)
  * Outpatient: Therapist In Private Practice (TPP), Physician, Non-Physician Practitioner (NPP), long-term care facility, hospital-based outpatient therapy clinic, outpatient rehabilitation facility (ORF), comprehensive outpatient rehabilitation facility (CORF)

  
Medicare coverage requirements state that rehabilitation services must be
provided and/or supervised by a qualified clinician i.e., physician, non-
physician practitioner (NPP), qualified physical therapist (PT), occupational
therapist (OT), speech-language pathologist (SLP), or appropriately
supervised/qualified therapy assistant.  
  
 **_Inpatient SNF Setting_**

**  
Therapy Aides**  
  
Therapy aides cannot provide skilled services. However, the time that a
therapy aide spends on set-up preceding skilled therapy may be coded on the
Minimum Data Set (MDS) (e.g., set up the treatment area for wound therapy) and
should be coded under the appropriate mode for the skilled therapy
(individual, concurrent, or group) in O0400. The therapy aide must be under
direct supervision of the therapist or assistant.  
  
 **Therapy Students**  
  
Therapy students are not required to be in line-of-sight of the supervising
therapist/assistant. The determination of whether or not a student is ready to
treat patients without line-of-sight supervision is left to the discretion of
the supervising therapist/assistant. Time may be coded on the MDS when the
therapist provides skilled services and direction to a student who is
participating in the provision of therapy. All state and professional practice
guidelines for student supervision must be followed.  
  

  * Individual therapy is for treatment of one patient at a time. When a therapy student is involved the minutes may be coded when only one patient is being treated by the therapy student and the supervising therapist/assistant. The supervising therapist/assistant cannot be treating or supervising another individual and he/she must be available to immediately assist the student as needed.
  * Concurrent therapy is for treatment of two residents who are performing different activities at the same time and are both in line-of sight of the treating therapist/assistant. When a therapy student is involved the minutes may be coded when one of the following occurs:   
  

    * Student is treating one patient and the supervising therapist/assistant is treating another patient and both patients are in line of sight of the therapist/assistant or student; or
    * Student is treating two patients both of whom are in line-of-sight of the student and the therapist/assistant is not treating any patients and is not supervising other individuals; or
    * Student is not treating any patients and the supervising therapist/assistant is treating two patients at the same time both of whom are in line-of-sight.
  * Group therapy is for treatment of four patients who are performing the same or similar activities and are supervised by a therapist/assistant who is not supervising any other individuals. When a therapy student is involved with group therapy the minutes may be coded when one of the following occurs:  

    * Student is providing group treatment and the supervising therapist/assistant is not treating any patient and is not supervising other individuals (students or patients); or
    * Supervising therapist/assistant is providing group treatment and the student is not treating any patient.

  
**_Outpatient Therapy Setting_**

**Therapy Aides**  
  
Therapy aides cannot provide skilled services. Also, unskilled service minutes
provided by the therapy aide cannot be counted and are not reimbursable even
when provided under direct supervision by the qualified therapist or assistant
e.g.  
  

  * The patient arrived at the clinic and worked in the gym with the therapy aide for 15 minutes, then the qualified therapist provided direct patient treatment for 20 minutes, then the patient worked for another 15 minutes in the gym with the therapy aide. Total of 20 individual minutes of service were provided by the qualified clinician and are billable for the session.
  * The patient arrived at the clinic and received direct patient treatment with the qualified therapist for 10 minutes, then the patient worked in the gym with a qualified therapy assistant for 15 minutes, then the patient received direct patient treatment with the qualified therapist for an additional 15 minutes. Total of 40 individual minutes of service were provided by qualified clinicians and are billable for the session.

  
**Therapy Students**  
  
Services provided by therapy students are not reimbursable even if provided
under direct supervision of the therapist/assistant. However, when a student
is in the room, the time that a qualified clinician spends with the patient is
reimbursable when the medical record supports:  
  

  * The qualified clinician is present and in the room for the entire session. The student may participate in the delivery of services only when the qualified clinician is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
  * The qualified clinician is not engaged in treating another patient or doing other tasks at the same time and is present in the room guiding the student in service delivery when the therapy student is participating in the provision of services.
  * The qualified clinician is responsible for the services and signs all documentation. A student may also sign but payment is for the clinician's service and not for the student's services.

  
When a therapy student is involved the skilled minutes of the qualified
clinician may be counted and coded when all requirements listed above are met.
For additional information, see the attached article _"Medical Necessity of
Therapy Services"_ in the Related Local Coverage Documents link below.  
  
 **Sources**  
  

  * CMS, Resident Assessment Instrument Manual (RAI) Version 3.0, Section O
  * CMS Medicare Learning Network, Medicare Outpatient Therapy Billing
  * Internet Only Manual (IOM), [Medicare Benefit Policy Manual](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf), Publication 100-02, Chapter 15, Sections 220(A), 230.230.6