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  • Private Practices and Rehabilitation Agencies, CMS Requirements – Table Data

Private Practices and Rehabilitation Agencies, CMS Requirements – Table Data

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
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:
  • OSHA
  • ADA
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

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