(Medicare Benefit Policy Manual)

Therapists may bill and be paid for the provision of services in the following scenarios:    The qualified practitioner is present and in the room for the entire session.  The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.    The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.    The qualified practitioner is responsible for the services and as such, signs all documentation.  (A student may, of course, also sign but it is not necessary since the Part B payment is for the clinicians service, not for the students services).   2.  Therapy Assistants as Clinical Instructors   Physical therapist assistants and occupational therapy assistants are not precluded from serving as clinical instructors for therapy students, while providing services within their scope of work and performed under the direction and supervision of a licens ed physical or occupational therapist to a Medicare beneficiary.   3.  Services Provided Under Part A and Part B   The payment methodologies for Part A and B therapy services rendered by a student are different.  Under the MPFS (Medicare Part B), Medicare pays for services provided by physicians and practitioners that are specifically authorized by statute.  Students do not meet the definition of practitioners under Medicare Part B.  Under SNF PPS, payments are based upon the case mix or Resource Utilization Group (RUG) category that describes the patient.  In the rehabilitation groups, the number of therapy m inutes delivered to the patient determines the RUG category.  Payment levels for each category are based upon the costs of caring for patients in each group rather than providing specific payment for each therapy service as is done in Medicare Part B.   230.1 - Practice of Physical Therapy  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  A.  General   Physical therapy services are those services provided within the scope of practice of physical therapists and necessary for the diagnosis and treatment of impairments, functional limitations, disabilities or changes in physical function and health status.  (See Pub. 100- 03, the Medicare National Coverage Determinations Manual, for specific conditions or services.)  For descriptions of aquatic therapy in a community center pool see section 220C of this chapter.   B.  Qualified Physical Therapist Defined  Reference: 42CFR484.4   The new personnel qualifications for physical therapists were discussed in the 2008 Physician Fee Schedule.  See the Federal Register of November 27, 2007, for the full text.  See also the correction notice for this rule, published in the Federal Register on January 15, 2008.   The regulation provides that a qualified physical therapist (PT) is a person who is licensed, if applicable, as a PT by the state in which he or she is practicing unless licensure does not apply, has graduated from an accredited PT education program and passed a national examination approved by the state in which PT services are provided.  The phrase, by the state in which practicing includes any authorization to practic e provided by the same state in which the service is provided, including temporary licensure, regardless of the location of the entity billing the services.  The curriculum accreditation is provided by the Commission on Accreditation in Physical Therapy Education (CAPTE) or, for those who graduated before CAPTE, curriculum approval was provided by the American Physical Therapy Association (APTA).  For internationally educated PTs, curricula are approved by a credentials evaluation organization either approved by the APTA or identified in 8 CFR 212.15(e) as it relates to PTs.  For example, in 2007, 8 CFR 212.15(e) approved the credentials evaluation provided by the Federation of State Boards of Physical Therapy (FSBPT) and the Foreign Credentialing Commission  on Physical Therapy (FCCPT).  The requirements above apply to all PTs effective January 1, 2010, if they have not met any of the following requirements prior to January 1, 2010.   Physical therapists whose current license was obtained on or prior to December 31, 2009, qualify to provide PT services to Medicare beneficiaries if they:    graduated from a CAPTE approved program in PT on or before December 31, 2009 (examination is not required); or,    graduated on or before December 31, 2009, from a PT program outside the U.S. that is determined to be substantially equivalent to a U.S. program by a credentials evaluating organization approved by either the APTA or identified in 8 CFR 212.15(e) and also passed an examination for PTs approved by the state in which practicing.   Or, PTs whose current license was obtained before January 1, 2008, may meet the requirements in place on that date (i.e., graduation from a curriculum approved by either the APTA, the Committee on Allied Health Education and Accreditation of the American M edical Association, or both).  Or, PTs meet the requirements who are currently licensed and were licensed or qualified as a PT on or before December 31, 1977, and had 2 years appropriate experience as a PT, and passed a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.   Or, PTs meet the requirements if they are currently licensed and before January 1, 1966, they were:    admitted to membership by the APTA; or    admitted to registration by the American Registry of Physical Therapists; or   graduated from a 4-year PT curriculum approved by a State Department of Education; or   licensed or registered and prior to January 1, 1970, they had 15 years of full-time experience in PT under the order and direction of attending and referring doctors of medicine or osteopathy.  Or, PTs meet requirements if they are currently licensed and they were trained outside the U.S. before January 1, 2008, and after 1928 graduated from a PT curriculum approved in the country in which the curriculum was located, if that country had an organization that was a member of the World Confederation for Physical Therapy, and that PT qualified as a member of the organization.  For outpatient PT services that are provided incident to the services of physicians/NPPs, the requirement for PT licensure does not apply; all other personnel qualifications do apply.  The qualified personnel providing PT services incident to the services of a physician/NPP must be trained in an accredited PT curriculum.  For example, a person who, on or before December 31, 2009, graduated from a PT curriculum accredited by CAPTE, but who has not passed the national examination or obtained a license, could provide Medicare outpatient PT therapy services incident to the services of a physician/NPP if the physician assumes responsibility for the services according to the incident to policies.  On or after January 1, 2010, although licensure does not apply, both education and examination requirements that are effective January 1, 2010, apply to qualified personnel who provide PT services incident to the services of a physician/NPP.  C.  Services of Physical Therapy Support Personnel   Reference: 42CFR 484.4   Personnel Qualifications.  The new personnel qualifications for physical therapist assistants (PTA) were discussed in the 2008 Physician Fee Schedule.  See the Federal Register of November 27, 2007, for the full text.  See also the correction notice for this rule, published in the Federal Register on January 15, 2008.  The regulation provides that a qualified PTA is a person who is licensed as a PTA unless licensure does not apply, is registered or certified, if applicable, as a PTA by the state in which practicing, and graduated from an approved curriculum for PTAs, and passed a national examination for PTAs.  The phrase, by the state in which practicing includes any authorization to practice provided by the same state in which the service is provided, including temporary licensure, regardless of the location or the entity billing for the services.  Approval for the curriculum is provided by CAPTE or, if internationally or military trained PTAs apply, approval will be through a credentialing body for the curriculum for PTAs identified by either the American Physical Therapy Association or identified in 8 CFR 212.15(e).  A national examination for PTAs is, for example the one furnished by the Federation of State Boards of Physical Therapy.  These requirements above apply to all PTAs effective January 1, 2010, if they have not met any of the following requirements prior to January 1, 2010.  Those PTAs also qualify who, on or before December 31, 2009, are licensed, registered or certified as a PTA and met one of the two following requirements:  1.  Is licensed or otherwise regulated in the state in which practicing; or  2.  In states that have no licensure or other regulations, or where licensure does not apply, PTAs have:  o graduated on or before December 31, 2009, from a 2- year college- level program approved by the APTA or CAPTE; and   o effective January 1, 2010,  those PTAs must have both graduated from a CAPTE approved curriculum and passed a national examination for PTAs; or  PTAs may also qualify if they are licensed, registered or certified as a PTA, if applicable and meet requirements in effect before January 1, 2008, that is,   they have graduated before January 1, 2008, from a 2 year college level program approved by the APTA; or   on or before December 31, 1977, they were licensed or qualified as a PTA and passed a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service.   Services.   The services of PTAs used when providing covered therapy benefits are included as part of the covered service.  These services are billed by the supervising physical therapist.  PTAs may not provide evaluative or assessment services, make clinical judgme nts or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service.  They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws.  A physical therapist must supervise PTAs.  The level and frequency of supervision differs by setting (and by state or local law).  General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless s tate practice requirements are more stringent, in which case state or local requirements must be followed.  See specific settings for details.  For example, in clinics, rehabilitation agencies, and public health agencies, 42CFR485.713 indicates that when a PTA provides services, either on or off the organizations premises, those services are supervised by a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days or more frequently if required by state or local laws or regulation.   The services of a PTA shall not be billed as services incident to a physician/NPPs service, because they do not meet the qualifications of a therapist.   The cost of supplies (e.g., theraband, hand putty, electrodes) used in furnishing covered therapy care is included in the payment for the HCPCS codes billed by the physical therapist, and are, therefore, not separately billable.  Separate coverage and bill ing provisions apply to items that meet the definition of brace in 130.   Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare.  Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.   D.  Application of Medicare Guidelines to PT Services   This subsection will be used in the future to illustrate the application of the above guidelines to some of the physical therapy modalities and procedures utilized in the treatment of patients.   230.2 - Practice of Occupational Therapy  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  A.  General   Occupational therapy services are those services provided within the scope of practice of occupational therapists and necessary for the diagnosis and treatment of impairments, functional disabilities or changes in physical function and health status.  (See  Pub. 100-03, the Medicare National Coverage Determinations Manual, for specific conditions or services.)   Occupational therapy is medically prescribed treatment concerned with improving or restoring functions which have been impaired by illness or injury or, where function has been permanently lost or reduced by illness or injury, to improve the individuals a bility to perform those tasks required for independent functioning.  Such therapy may involve:    The evaluation, and reevaluation as required, of a patients level of function by administering diagnostic and prognostic tests;    The selection and teaching of task -oriented therapeutic activities designed to restore physical function; e.g., use of woodworking activities on an inclined table to restore shoulder, elbow, and wrist range of motion lost as a result of burns;    The planning, implementing, and supervising of individualized therapeutic activity programs as part of an overall active treatment program for a patient with a diagnosed psychiatric illness; e.g., the use of sewing activities which require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient;