Question: Is it true that Medicare guidelines have changed so that to bill for physical therapy services, the services have to be performed by licensed PT/PTA or MD? I know a lot of places around my community that bill PT services and they are not provided by a licensed PT/PTA or MD. I was told by a friend that Medicare will not investigate this complaint if it is reported by an anonymous tip unless it is a complaint by a patient. Any suggestions what PT/PTAs should do? Can the APTA do anything to stop this? Can the APTA urge other health insurance payers (PPO, workers compensation, etc.) to follow Medicare guidelines for PT services so that they only pay for services performed by PT/PTA or MD?

Answer: In June 2005, CMS issued completely new guidelines for who could provide physical therapy and bill the Medicare program. Only a licensed physical therapist or physical therapist assistant under their supervision can bill the Medicare program. This applies to all providers of therapy services with the exception of physician “incident-to” services. A physician or non-physician practitioners (Clinical Nurse Specialist, Physician Assistant or Nurse Practitioner) who is licensed by the state to practice physical therapy can provide services and bill Medicare. They can utilize a licensed or unlicensed physical therapist to provide “incident to” therapy.

No other health care professional or tech can be utilized or substituted. A therapist assistant cannot work “incident to” a physician because they must be supervised by a licensed physician therapist to bill Medicare. One cannot bill Medicare for physical therapy given by athletic trainers, massage therapists, exercise physiologists, rehab techs or aides.

We have not heard that CMS is ignoring complaints, that the regulations are being ignored and non-qualified personnel are being used to provide and bill the service. In fact, it is recognized as Medicare FRAUD, when services are being billed as physical therapy when provided by a person not authorized to do so.

As far as the APTA is concerned, they are our professional organization and as such can only advise or educate insurance providers in appropriate use of licensed personnel; they cannot enforce it.

Question: We vaguely remember an article in ADVANCE regarding upcoming legislation mandating licensed caregivers to seek a "Medicare Provider Number". Is this an NPI number? Who needs to apply for such a number and, how does one go about applying for the required number? Is the requirement specific to certain types of settings (i.e. OP only, all settings, etc.). Please explain and define ANY requirements and processes to ensure compliance as a licensed PT.

Answer: An NPI, or National Provider Identifier, number is required by any organization, institution or individual that directly bills the Medicare program. This means as therapist, only those in private practice need to obtain this number in order to bill Medicare appropriately on the CMS1500 form. All other therapists that are employed by companies that provide Medicare services and bill under that organization’s own NPI. 

An NPI number is obtained through the CMS website at https://nppes.cms.hhs.gov/NPPES/. There is no charge for this number and the time to complete the form is about 20 minutes. If you are planning on providing therapy as a private practitioner, then you need this number before you can apply for your Medicare provider number. If you are planning to work for any hospital, SNF, home health agency or rehabilitation agency, this is not a requirement.

Pauline Franko is owner of Encompass Consulting & Education, LLC, a rehabilitation consulting and education company based in Tamarac, FL. The company’s “Direction on Demand” consulting and educational services specialize in providing the healthcare professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and all Outpatient settings. As a principle in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance programs to Rehab Agencies. Danna Mullins is an associate with Encompass. You may contact the authors through the Encompass website at www.encompassmedicare.com or directly at (954) 720-4087