Page 227 - Medicare Benefit Policy Manual

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 allows 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 physician’s/NPP’s
service. However, if a PT and PTA (or an OT and OTA) are both employed in a
physician’s 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 physician’s 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 physician’s service, because they do not meet the qualification
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/NPP’s 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 physician’s/NPP’s office or the
beneficiary’s 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