Common Questions and Answers Regarding Physical Therapist Assistants

By Rick Gawenda, PT

Physical therapist assistants (PTAs) are integral members of the private practices where they are employed. However, care must be taken to ensure the work they do is in compliance with all legal regulations, as those that apply to PTAs are different from those that apply to physical therapists. In this article, I will provide the answers to some of the more common questions I receive regarding PTAs.

QUESTION

Can PTAs obtain a National Provider Identification (NPI) number?

ANSWER

Yes, PTAs can obtain a NPI number by completing an online application at https://nppes.cms.hhs.gov/#/. For additional information on how to apply for a NPI, go to https://nppes.cms.hhs.gov/assets/How_to_apply_for_an_NPI_online.pdf.

QUESTION

Can PTAs who practice in the private practice setting enroll in the Medicare program?

ANSWER

No. When a PTA treats a Medicare beneficiary for outpatient therapy services in the private practice setting, their services are billed under the NPI number of the therapist who is providing the required level of supervision and who is also enrolled in the Medicare program.¹

QUESTION

Can PTAs who practice in the private practice setting enroll with commercial insurance carriers?

ANSWER

Generally, the answer is no. For the majority of commercial insurance carriers, when a PTA treats a patient covered by commercial insurance, their services are billed under the NPI number of the therapist who is providing the required level of supervision and who is also enrolled/credentialed with that commercial insurance carrier.

It would be the clinic’s responsibility to verify with each commercial insurance carrier as to whether or not a PTA must enroll and/or credential with that commercial insurance carrier.

QUESTION

Under Medicare Part B, what type of supervision does the PTA require in the private practice setting?

ANSWER

In a private practice setting (submit claims on a 1500-claim to Medicare), the Medicare program requires direct supervision of the PTA by the PT. In CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 230.4B, the Centers for Medicare and Medicaid Services (CMS) defines direct supervision as such: “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.”²

Due to COVID-19, CMS has modified their definition of direct supervision until December 31st of the year in which the public health emergency is declared over. This modified definition allows an assistant treating a Medicare beneficiary in a private practice setting to be directly supervised by the therapist via the availability of real-time 2-way audio/visual telecommunication.³

Examples of this modified definition are that the therapist would be readily available to assist the assistant via Zoom or FaceTime. However, if your state practice act requires direct supervision of the assistant by the therapist and the definition of direct supervision is the therapist must be on the premise when an assistant is providing therapy services, then you must follow your state practice act since it is more restrictive/stringent than CMS’s modified definition of direct supervision.

QUESTION

Under Medicare Part B, what type of supervision does the PTA require in the non-private practice setting?

ANSWER

In a non-private-practice setting, such as a skilled nursing facility, hospital outpatient therapy department, rehabilitation agency, comprehensive outpatient rehabilitation facility, or home health agency providing outpatient therapy in the home, the Medicare program requires general supervision of the PTA by the PT and general supervision of the OTA by the OT unless your state practice act is more restrictive/stringent. General supervision means the PT or OT is readily available to assist the PTA or OTA respectively but does not need to be on the premises during the time the PTA or OTA is treating the Medicare beneficiary.³

Again, if your state practice act requires direct supervision of the assistant by the therapist, then your state practice act is more restrictive/stringent than the Medicare program, and you must follow your state practice.

QUESTION

If the normal supervising therapist of an assistant is off work for whatever reason, how are the services of an assistant billed to Medicare and other insurance carriers?

ANSWER

In this instance, the services provided by the assistant would be billed under the NPI number of the therapist who is providing the required level of supervision and who is also enrolled/credentialed with Medicare and the applicable commercial insurance carrier. This would be a different therapist, since the regular therapist is not at work. This answer is applicable to claims submitted on the CMS 1500-claim form.

QUESTION

Can a PTA perform an initial evaluation and/or reevaluation?

ANSWER

No! An evaluation and reevaluation can only be performed by a PT or an OT. In CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 220.3C, CMS states, “Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care. A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or re-evaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.”⁴

Also, read your therapy state practice act. Does it allow a PTA or an OTA to participate in an evaluation or re-evaluation? If no, then that is the most stringent and that is what you must adhere to.

QUESTION

Can a PTA write a progress report?

ANSWER

For the answer, you need to look at your respective therapy state practice act. Does the therapy practice act allow or prohibit a PTA or an OTA from writing a progress report? My review of numerous therapy state practice acts has shown that many do not allow a PTA to write a progress report.

If your practice act does allow a PTA to write a progress report, you then must check with each insurance carrier to determine what their policies, rules, and regulations regarding PTAs writing a progress report are. For example, the Centers for Medicare and Medicaid Services (CMS), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 220.3D states, “PTAs or OTAs may write elements of the progress report dated between clinician reports. Reports written by assistants are not complete progress reports.”⁵ The reason why progress reports written by assistants are not complete Progress Reports is because for Medicare, the following must be written by a therapist and not an assistant:

• Assessment of improvement, extent of progress (or lack thereof) toward each goal;
• Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report; and
• Changes to long- or short-term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.
• Functional documentation is required as part of the progress report at the end of each progress reporting period.

The safest bet is to have the therapist write the progress report(s).

QUESTION

Can a PTA write a discharge report?

ANSWER

For the answer, you need to look at your respective therapy state practice act. Does the therapy practice act allow or prohibit a PTA from writing a discharge report. My review of numerous therapy state practice acts shows that do not allow a PTA to write a discharge report.

If your practice act does allow a PTA to write a discharge report, you then must check with each insurance carrier to determine what their policies, rules, and regulations regarding PTAs writing a discharge report are. For example, the Centers for Medicare and Medicaid Services (CMS), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 220.3D states, “The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge.”⁵

In Section 220, CMS defines clinician as such: “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.”6 I hope you found this article informative. As always, this article is not intended to and does not serve as legal advice or as consultative services but is for general information purposes only.

References:

¹CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 230.1C https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

²CMS Publication 100-02, Medicare Benefit Policy Manual

³CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 230.4B, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

⁴Medicare Program; CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; and Provider and Supplier Prepayment and Post-payment Medical Review Requirements, https://www.federalregister.gov/d/2021-23972

⁵CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 220.3D, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

⁶CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 220, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Rick Gawenda, PT, is the founder and president of Gawenda Seminars & Consulting, Inc. He may be reached at info@gawendaseminars.com and on Twitter @gawendaseminars.