Page 226 - Medicare Benefit Policy Manual

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 therapist’s office under arrangements
with hospitals in rural communities and public health agencies (or services provided in
the beneficiary’s 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
therapist’s service.

Qualifications of Auxiliary Personnel. Therapy services appropriately billed incident to a
physician’s/NPP’s 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 physician’s/NPP’s service, the qualified personnel who perform
the service do not need to have a license to practice therapy, unless it is required by state