(Medicare Benefit Policy Manual)

The contractor considers a therapist to be in private practice if the therapist maintains office space at his or her own expense and furnishes services only in that space or the patients home.  Or, a therapist is employed by another supplier and furnishes  services in facilities provided at the expense of that supplier.   The therapist need not be in full -time private practice but must be engaged in private practice on a regular basis; i.e., the therapist is recognized as a private practitioner and for that purpose has access to the necessary equipment to provide an adequat e program of therapy.   The therapy services must be provided either by or under the direct supervision of the TPP.  Each TPP should be enrolled as a Medicare provider.  If a therapist is not enrolled, the services of that therapist must be directly supervised by an enrolled ther apist.  Direct supervision requires that the supervising private practice therapist be present in the office suite at the time the service is performed.  These direct supervision requirements apply only in the private practice setting and only for therapis ts and their assistants.  In other outpatient settings, supervision rules differ.  The services of support personnel must be included in the therapists bill.  The supporting personnel, including other therapists, must be W -2 or 1099 employees of the TPP or other qualified employer.   Coverage of outpatient therapy under Part B includes the services of a qualified TPP when furnished in the therapists office or the beneficiarys home.  For this purpose, home includes an institution that is used as a home, but not a hospital, CAH or SN F, (Federal Register Nov. 2, 1998, pg 58869).  C.  Assignment   Reference:  Nov. 2, 1998 Federal Register, pg. 58863 See also Pub. 100- 04 chapter 1, 30.2.   When physicians, NPPs, or TPPs obtain provider numbers, they have the option of accepting assignment (participating) or not accepting assignment (nonparticipating).  In contrast, providers, such as outpatient hospitals, SNFs, rehabilitation agencies, and CORFs, do not have the option.  For these providers, assignment is mandatory.  If physicians/NPPs, or TPPs accept assignment (are participating), they must accept the Medicare Physician Fee Schedule amount as payment. Medicare pays 80% and the patient is responsible for 20%.  In contrast, if they do not accept assignment, Medicare will only pay 95% of the fee schedule amount.  However, when these services are not furnished on an assignment- related basis, the limiting charge applies.  (See 1848(g)(2)(c)  of the Act.)   NOTE :  Services furnished by a therapist in the therapists office under arrangements with hospitals in rural communities and public health agencies (or services provided in the beneficiarys home under arrangements with a provider of outpatient physical or occupational therapy services) are not covered under this provision.  See section 230.6.  230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Non-Physician Practitioners (NPP)  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)  References: 1861(s)(2)(A)  of the Act  42 CFR 410.10(b) 42 CFR 410.26 Pub. 100-02, ch. 15, 60.  The Benefit.   Therapy services have their own benefit under 1861 of the Social Security Act and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals.  The statute 1862(a)(20)  requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions --other than licensing-- that would apply to a therapist.  (For example, see coverage requirements in Pub. 100-08, chapter 13, 13.5.1(C), Pub. 100-04, chapter 5 , and also the requirements of this chapter, 220 and 230.  Incident to a Therapist.  There is no coverage for services provided incident to the services of a therapist.  Although PTAs and OTAs work under the supervision of a therapist and their services may be billed by the therapist, their services are covered under the benefit for therapy services and not by the benefit for services incident to a physician/NPP.  The services furnished by PTAs and OTAs are not incident to the therapists service.   Qualifications of Auxiliary Personnel.  Therapy services appropriately billed incident to a physicians/NPPs service shall be subject to the same requirements as therapy services that would be furnished by a physical therapist, occupational therapist or speech-language pathologist in any other outpatient setting with one exception.  When therapy services are performed incident to a physicians/NPPs service, the qualified personnel who perform the service do not need to have a license to practice therapy, unless it is required by state law.  The qualified personnel must meet all the other requirements except licensure.  Qualifications for therapists are found in 42CFR484.4 and in section 230.1, 230.2, and 230.3 of this chapter.  In effect, these rules require that the person who furnishes the service to the patient must, at least, be a graduate of a program of training for one of the therapy services as described above.  Regardless of any state licensing that al lows other health professionals to provide therapy services, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech -language pathology.  That means that the services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as therapy services.  The services of PTAs and OTAs also may not be billed incident to a physicians/NPPs service.  However, if a PT and PTA (or an OT and OTA) are both employed in a physicians office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT).  (See Section 230.4 for private practice rules on billing services performed in a physicians office.)  If the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA billed incident to the physicians service, because they do not meet the qualifica tion standards in 42CFR484.4 .  Therapy services provided and billed incident to the services of a physician/NPP also must meet all incident- to requirements in 60 of this chapter.  Where the policies have different requirements, the more stringent requirement shall be met.  For example, when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings.  The mandatory assignment provision does not apply to therapy services furnished by a physician/NPP or "incident to" a physician's/NPPs service.  However, when these services are not furnished on an assignment -related basis; the limiting charge applies.   For emphasis, following are some of the standards that apply to therapy services billed incident -to the services of a physician/NPP in the physicians/NPPs office or the beneficiarys residence.   A.  Therapy services provided to the beneficiary must be covered and payable outpatient rehabilitation services as described, for example, in this section as well as Pub. 100- 08, chapter 13, 13.5.1.  B.  Therapy services must be provided by, or under the direct supervision of a physician (a doctor of medicine or osteopathy; a doctor of podiatry or a doctor of optometry when treating patients within the state scope of practice in the state in which the services are provided) or NPP who is legally authorized to practice therapy services by the state in which he or she performs such function or action.  Direct supervision requirements are the same as in 42CFR410.32(b)(3).  The supervisor must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.  It does not mean that the physician/NPP must be present in the same room in the office where the service is performed.   C.  The services must be of a level of complexity that require that they be performed by a therapist or under the direct supervision of the therapist, physician/NPP who is licensed to perform them.  Services that do not require the performance or supervisi on of the therapist, physician/NPP, are not considered reasonable or necessary therapy services even if they are performed or supervised by a physician/NPP or other qualified professional.   D.  Services must be furnished under a plan of treatment as in 220.1.2 of this chapter.  The services provided must relate directly to the physician/NPP service to which it is incident.   230.6 - Therapy Services Furnished Under Arrangements With Providers and Clinics (Rev. 36, Issued: 06- 24-05, Effective: 06 -06-05, Implementation: 06- 06-05)  References:   See also  Pub. 100- 01, chapter 5, 10.3.  A.  General   For rules regarding services provided under arrangement, see Pub. 100- 01, chapter 5, 10.3.  A provider may have others furnish outpatient therapy (physical therapy, occupational therapy, or speech -language pathology) services through arrangements under which receipt of payment by the provider for the services discharges the liability of the beneficiary or any other person to pay for the service.   However, it is not intended that the provider merely serve as a billing mechanism for the other party.  For such services to be covered the provider must assume professional responsibility for the services.  The providers professional supervision over the services requires application of many of the same controls that are applied to services furnished by salaried employees.  The provider must:    Accept the patient for treatment in accordance with its admission policies;    Maintain a complete and timely clinical record on the patient which includes diagnosis, medical history, orders, and progress notes relating to all services received;    Maintain liaison with the attending physician/NPP with regard to the progress of the patient and to assure that the required plan of treatment is periodically reviewed by the physician/NPP;    Secure from the physician/NPP the required certifications and recertifications; and    Ensure that the medical necessity of such service is reviewed on a sample basis by the agencys staff or an outside review group.   In addition, when a provider provides outpatient services under an arrangement with others, such services must be furnished in accordance with the terms of a written contract, which provides for retention by the provider of responsibility for and control a nd supervision of such services.  The terms of the contract should include at least the following:    Provide that the therapy services are to be furnished in accordance with the plan of care established according to Medicare policies for therapy plans of care in section 220.1.2 of this chapter;    Specify the geographical areas in which the services are to be furnished;    Provide that contracted personnel and services meet the same requirements as those which would be applicable if the personnel and services were furnished directly by the provider;    Provide that the therapist will participate in conferences required to coordinate the care of an individual patient;    Provide for the preparation of treatment records, with progress notes and observations, and for the prompt incorporation of such into the clinical records of the clinic;   Specify the financial arrangements.  The contracting organization or individual may not bill the patient or the health insurance program; and    Specify the period of time the contract is to be in effect and the manner of termination or renewal.   B.  Special Rules for Hospitals    A hospital may bill Medicare for outpatient therapy (physical therapy, occupational therapy, or speech- language pathology) services that it furnishes to its outpatients either directly or under arrangements in the hospital's outpatient department.  If a hospital furnishes medically necessary therapy services in its outpatient department to individuals who are registered as its outpatients, those services must be billed directly by the hospital using bill type 13X or 85X for critical access hospitals.  Note that services provided to residents of a Medicare- certified SNF may not be billed by the hospital as services to its outpatients.    When a hospital sends its therapists to the home of an individual who is registered as an outpatient of the hospital but who is unable, for medical reasons, to come to the hospital to receive medically necessary therapy services, the services must meet the requirements applicable to outpatient hospital therapy services, as set forth in the regulations and applicable Medicare manuals.  The hospital may bill for those services directly using bill type 13X or 85X for critical access hospitals.    If a hospital sends its therapists to provide therapy services to individuals who are registered as its outpatients and who are residing in the non- certified part of a SNF, or in another residential setting (e.g., a group home, assisted living facility or domiciliary care home), the hospital may bill for the services as hospital outpatient services if the services meet the requirements applicable to outpatient hospital therapy services, as set forth in the regulations and applicable Medicare manuals.