Condition/Requirement |
|
Private Practice |
|
Rehabilitation Agency |
| Condition |
Y/N |
Comment |
Y/N |
Comment |
| Clinical Record Audits |
? |
Not mandated, but auditing would be considered a proactive fraud and abuse prevention activity |
Yes |
Required in the Conditions of Participation (C of P) |
| Employee Safety & Emergency Education and Training |
Yes |
OSHA’s 29 CFR 1910 |
Yes |
C of P & OSHA |
| Infection Control/Bloodborne Pathogens (BBP) Policies/Procedures |
Yes |
OSHA/Bloodborne Pathogens Standard |
Yes |
C of P & OSHA |
| Hazard Protection |
Yes |
OSHA/Hazard Communication Standard |
Yes |
C of P & OSHA |
| Patient Safety |
Yes |
OSHA |
Yes |
C of P & OSHA |
| Environment & Equipment Preventive Maintenance |
Yes |
OSHA |
Yes |
C of P & OSHA |
| Personnel Policies |
? |
Proactive for workers compensation (WC) and professional liability risk management and avoidance of “negligent hiring and retention” lawsuits |
Yes |
C of P |
| Patient Care Policies |
? |
Professional ethics, practice acts, and professional liability risk management |
Yes |
C of P |
| Independent Agent/Staffing |
Yes |
Contractual terms required |
Yes |
C of P |
| Patient Record Management & Retention |
Yes |
Health Insurance Portability and Accountability Act (HIPAA) |
Yes |
C of P< & HIPAA |
BONUS INFORMATION |
|
|
|
|
| Payment-Billing Variances |
|
|
|
|
| Physician Fee Schedule |
Yes |
|
Yes |
|
| Billing on CMS 1500 Form |
Yes |
Physical Therapist (PT) and Practice’s National Provider Identifier (NPI) |
No |
|
| Billing on CMS UB-04 |
No |
|
Yes |
RA’s NPI |
| Billing Frequency Limitations |
No |
Daily or To Be Determined |
Yes |
Monthly |
| Coding & Reporting |
|
|
|
|
| Use of Correct Coding Initiative (CCI) Edit (59) |
Yes |
|
Yes |
|
| Use of Advance Beneficiary Notice (ABN) |
Yes |
|
Yes |
|
| Application of Therapy Cap (KX) |
Yes |
|
Yes |
|
| Reporting of Functional Limitations |
Yes |
|
Yes |
|
| Reporting of Physician Quality Reporting Scale (PQRS) Measures |
Yes |
|
No |
UB-04 limitation |
| Enrollment Variances |
|
|
|
|
| Enrollment is required for each therapist who treats Medicare patients |
Yes |
Claims have to be held until the therapist receives a Medicare Number (PTAN) |
No |
Therapists have no individual screening or enrollment requirements |
| State Agency Survey Required |
No |
|
Yes |
After the CMS enrollment application has been approved, the state agency or an accrediting organization must perform an in-depth physical plant and provider compliance survey based on the Conditions of Participation for the RA. There are fees for the survey as well as annual fees based on full-time equivalents (FTEs). There are multiple approval and review levels; time from beginning to end varies from 90-160 days |
| Therapists Application Forms: CMS 855i, 855r & sometimes the CMS 460 |
Yes |
|
No |
|
| Practice Application Forms: 855b, CMS 460, EFT 588 |
Yes |
|
Yes |
855a & EFT 588 |
| Enrollment/Revalidation Application Fees |
No |
|
Yes |
~$500 |
| Revalidation Applications: Practice & therapists |
Yes |
Both the practice and the therapists |
Yes |
Practice (RA) only |
| Certified Institutional Provider |
No |
|
Yes |
Only RA |
| Enrolled Supplier |
Yes |
Both the practice and the therapists |
Yes |
|
| Reassignment requirements (the PT has the option to grant the practice the right to receive payment for his/her services) |
Yes |
Both the practice and the therapists |
No |
The RA is automatically the billing entity; no reassignment is necessary |
| Therapist must have an NPI (national provider identification number) for billing purposes |
Yes |
Both the practice and the therapists |
No |
Only the RA is required to have an NPI and all charges are billed under the RA NPI |
| Practice/therapist participation (assignment from patient) |
Yes |
The therapist/practice may elect to accept patient assignment |
No |
RA must accept patient assignments |
| Site Survey related to Medicare enrollment/revalidation, practice site change, or the addition of a new therapist |
Yes |
This is a “proof” of existence survey; it is not an in-depth survey of charts, conditions, or compliance |
No |
RA is in the low-risk category but is subject to the State Agency Survey (see above) |
| Miscellaneous Variances |
|
|
|
|
| General supervision of a physical therapist assistant |
No |
Onsite supervision is required in the private practice setting |
Yes |
Unless state law is more stringent, Physical Therapy Assistants (PTAs) do not have to have onsite supervision |
| Two Person Duty Requirement |
No |
|
Yes |
Two individuals present during patient treatment |
| Facility Administrator |
No |
Private practices do not have to designate an administrator but some states do require that they designate a “charge therapist” |
Yes |
Yes RA is required to have a full-time administrator; this person needs to be qualified but does not have to be a physical therapist |
| Services can be provided in the patient’s home, Part B Skilled Nursing Facilities/Nursing Facilities, Assisted Living Facilities (SNF, NFs, ALFs) and Independent Living Facilities |
Yes |
|
Yes |
|
| Practice Site Change or Addition |
No |
The private practice must submit a practice site relocation, termination, or addition notification, via the 855b or 855i, within 30 days of the change but it is not typically subject to approval
|
Yes |
When an existing RA intends to move its primary site or if it intends to move any of its approved extension locations to a new practice location or it desires to add a new practice location, it must first notify CMS within 90 days of the expected move or addition and seek approval from Medicare’s Regional Office before it can bill Medicare for covered services from the new address |
| Thirty-mile radius limitation for additional practice sites |
No |
|
Yes |
This only applies to RA if it relates to an extension site |
| Physical therapy or speech therapy (ST) must be provided at each practice site. Occupational Therapy (OT) cannot be the only service provided |
No |
|
Yes |
|
| Aquatic therapy provided in a community pool |
No |
The agreement with the community pool must indicate separate space but the pool does not need to be closed to the public |
Yes |
The pool must be closed to the public |
| Policies & Procedures |
Yes |
As a health care provider, the following are minimally required:
|
Yes |
RA must have policies and procedures in place in order to comply with the Conditions of Participation as well as those mentioned for PTPP |
