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Therapy Supervision

September 6, 2015 4 Comments

The word Rules on a cork notice boardTherapy supervision rules differ by venue in terms of Medicare, and may differ by state jurisdiction for Medicaid. Tricare does not have therapist supervision rules for private practice, as therapy assistants are not allowed by Tricare Military policy.  Medicare, Medicaid and Tricare supervision rules are payor rules.  There are also practice rules for supervision noted in your physical therapy, occupational therapy or speech-language pathology practice act which should be referenced in determining the establishment of the supervision policy in your clinic or practice.

Often times therapists end up working in a private practice after working in a hospital or a rehab agency and may inadvertently think that the same supervision rules apply.

Therapy Supervision – Know the Rules

The Medicare basis for therapy supervision rules for outpatient rehabilitation therapy services are the same as those for diagnostic tests defined in 42CFR410.32. (Code of Federal Regulations) Depending on the setting, the supervision levels include personal supervision (in the room), direct supervision (in the office suite), and general supervision (is available but not necessarily on the premises).

Per CMS ” Services that can be safely and effectively furnished by nonskilled personnel or by PTAs or OTAs without the supervision of therapists are not rehabilitative therapy services.”  In the Medicare Benefits Policy Manual, Chapter 15, CMS describes the services of a physical therapist assistant (PTA):

…..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 judgments 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.

This lays necessary policy guidance to describe supervision:

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 state practice requirements are more stringent, in which case state or local requirements must be followed.

For example, in clinics, rehab agencies, and public health agencies, 42CFR485.713 indicates:

that when a PTA provides services, either on or off the organization’s 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.

While the above examples addresses physical therapist assistants CMS also provides similar guidance for occupational therapy assistants (OTAs) in the Medicare Benefits Policy Manual, Chapter 15 at Section 230.2 (C).  CMS does not allow for the services of a speech-language pathology assistant to be billed to Medicare.

In a nutshell, PTAs and COTAs in private practice must have direct (onsite) supervision by the supervising PT or OT in order to bill Medicare.  PTAs and COTAs working in hospitals, rehab agencies and CORFs require general supervision, and the supervising therapist must be available, but does not need to be on the premises.  Review this blog post for guidance on Tricare and the use of PTAs in private practice.  If you are a Medicaid provider ensure that you know the supervision rules.  And in all instances reference an updated copy of the PT and OT practice acts in your state to ensure compliance with supervision rules.  Stay tuned for a future post on supervision and use of assistants will billing incident-to.

Do you have PTAs and COTAs providing services in your outpatient therapy rehab program?  Are these services billed to federal healthcare programs including Medicare, Medicaid and Tricare?  Is your supervision policy compliant with both payor polices and your practice act?

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (4)

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  1. Audrey says:

    Greetings,
    I find it unfortunate that you do not utilize or recognize assistants in your program. I am finding a lot of information for PTA’s practicing in out patient clinics regarding medicare. I have searched for similar information for COTA/L guidelines which are much less informative in the out patient setting. It appears that we may just be assuming the supervision is the same. All COTA’s have to take a national board certification exam and maintain continuing education to be able to practice as certified. For PTA’s this has not been required. Could you please send me the link which specifies that COTA’s specifically need direct supervision in the out patient setting within medicare guidelines?

    Thank you

  2. Hi Audrey – and thank you for your comment. I don’t have a program, so I wanted to clear that up, and I have nothing per se against COTAs! And I certainly recognize their education and expertise. The regulations regarding supervision by types, for all providers, are contained in the Statute. However, specific to outpatient therapy you can find the following definition in the MBPM: “SUPERVISION LEVELS for outpatient rehabilitation therapy services are the same as those for diagnostic tests defined in 42CFR410.32. Depending on the setting, the levels include personal supervision (in the room), direct supervision (in the office suite), and general supervision (physician/NPP is available but not necessarily on the premises).”

    Additionally the definition of a clinician indicates the supervision requirement: “The CLINICIAN is a term used in this manual and in Pub 100-04, chapter 5, section 10 or section 20, to refer to only a physician, nonphysician practitioner or a therapist (but not to an assistant, aide or any other personnel) providing a service within their scope of practice and consistent with state and local law. Clinicians make clinical judgments and are responsible for all services they are permitted to supervise. Services that require the skills of a therapist, may be appropriately furnished by clinicians, that is, by or under the supervision of qualified physicians/NPPs when their scope of practice, state and local laws allow it and their personal professional training is judged by Medicare contractors as sufficient to provide to the beneficiary skills equivalent to a therapist for that service.”

    Then to finally address your inquiry regarding a citation – this is provided very clearly in the MBPM: “An occupational therapist must supervise OTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for OTAs in all settings except private practice (which requires direct supervision) unless state 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 an OTA provides services, either on or off the organization’s premises, those services are supervised by a qualified occupational 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.”

    I hope that clarifies your question – all the answers are readily available in the therapy requirements noted in the Medicare Benefits Policy Manual.

  3. Josephine says:

    I was hoping for a clarification regarding supervisory visit requirement every 30 days for a PTA providing services. I am a PT who treats in an outpatient clinic and has direct supervision of the PTA. How does this supervisory visit differ from the progress report that is required every 10 treatment days?

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