Page 225 - Medicare Benefit Policy Manual

When the therapist who has a Medicare NPI is employed in a physician’s/NPP’s office
the services are ordinarily billed as services of the therapist, with the therapist identified
on the claim as the supplier of services. However, services of the therapist who has a
Medicare NPI may also be billed by the physician/NPP as services incident to the
physician’s/NPP’s service. (See §230.5 for rules related to therapy services incident to a
physician.) In that case, the physician/NPP is the supplier of service, the NPI of the
supervising physician/NPP is reported on the claim with the service and all the rules for
both therapy services and incident to services (§230.5) must be followed.

B. Private Practice Defined

Reference: Federal Register November, 1998, pages 58863-58869; 42CFR 410.38(b),
42CFR410.59, 42CFR410.60, 42CFR410.62

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
patient’s 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 adequate 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 therapist. 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 therapists and their assistants. In other
outpatient settings, supervision rules differ. The services of support personnel must be
included in the therapist’s 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 therapist’s office or the beneficiary’s home. For this purpose,
“home” includes an institution that is used as a home, but not a hospital, CAH or SNF,
(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